6/3/2018 1 ` Accredited Fellow, American Academy of Cosmetic Dentistry Fellow, International Academy for Dental Facial Esthetics Member of The American Society For Dental Aesthetics Former Faculty, UCLA Center For Esthetic Dentistry Todd Snyder, DDS, FAACD, FIADFE, ASDA Laguna Niguel, CA Aesthetic Dental Designs ® [email protected]
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632018
1
`
Accredited Fellow American Academy of Cosmetic Dentistry
Fellow International Academy for Dental Facial Esthetics
Member of The American Society For Dental Aesthetics
Former Faculty UCLA Center For Esthetic Dentistry
Todd Snyder DDS FAACD FIADFE ASDALaguna Niguel CA
Aesthetic Dental Designsreg
doctcsdentalcom
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Preparation Design
Retention form 25deg-8deg Resistance form Prepared tooth 4mm+ tall
Line of draw
07 mm - 20 mm All Ceramic15 mm - 20 mm PFMAbove images taken from Glidewell Laboratories
Preparation Design- Zirconia
Zirconia (1100mpa-1400mpa)
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3
Prep counter clockwise Less tissue damage (rotation is rolling on tissue) amp faster tooth reduction
Prep clockwise Tissue removal due to bur rotating opposite direction
rolling on tooth creates less reduction of tooth structure
Place a single cord after preparing interproximal area
bull Bur system that allows for easy depth reductionidentification
bull Retention 25deg-8deg (burs have 2deg-3deg)
bull Resistance form (boxgrooves)
bull Crown height (4mm+)
bull Reduction Variations
bull Full Gold (05mm+)
bull PFM (15-2mm)
bull All Ceramic
bull Lithium Disilicate
bull Zirconia 08mm
K0095 Preparation Kit (Brasseler USA)
Preparation Design
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Margin Refinement E-Statis Prep
(SciCan)
K0095 Preparation Kit (Brasseler USA)
Dent Mater 2008 Jul24(7)978-85 doi
101016jdental200711019 Epub 2008 Jan
15
Bond strength of self-etch adhesives to dentin
prepared with three different diamond burs
Ermis RB De Munck J Cardoso MV Coutinho
E Van Landuyt KL Poitevin A Lambrechts
P Van Meerbeek B
Oper Dent 2010 Nov-Dec35(6)624-33 doi
10234109-379-L
Effect of surface preparation on bond strength
of resin luting cements to dentin
Peerzada F Yiu CK Hiraishi N Tay FR King NM
Preparation DESIGNS-Burs
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Margin refinement with electric
handpiece 5-10000 rpms
Zirconium
Crowns
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Disposable Single Use Diamonds-medium or coarse grit
bull NeoDrys
bull NeoDiamonds
bull Bite-Check 18um
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Round end taper 1122811218
End Cutter 5014
Egg 1900
Modified Flap End Taper KR 08168
0512C1300F0710C 0116C0818C
Everyday Go To Minimally Invasive Burs
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8
Offer not valid for previous purchases or in conjunction with any other offer
Free Pack of NEODiamonds
NSK
NLZ Electric Handpieces
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Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
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Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
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Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
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FluidTissue Management
FluidTissue Management
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13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
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Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
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Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
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16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
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Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
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Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
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Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
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TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
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Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
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Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
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23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
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Bite Registration Importance
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25
Disposable Articulators
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Semi Adjustable
not on Hinge Axis
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Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
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28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
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30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
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Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
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Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
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Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
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Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
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35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
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Trays are unique and fit very well with minimal adjustments typically being needed
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Impression Trays
Impression Trays
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Impression Trays
Impression Trays
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Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
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Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
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ULTRADENTrsquoS NEW THERMO CLONE VPS
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Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
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Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
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Cracked toothKettenbach
Panasil Initial ContactKettenbach
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46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
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Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
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Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
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Simplified Provisionals
Siltech Putty Matrix
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Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
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Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
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52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
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53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
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54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
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56
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57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
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58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
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Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
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Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
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61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
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62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
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63
Zirconia Multi-layered
Zirconia Multi-layered
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64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
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65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
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66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
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67
Zirconia Aesthetics
Zirconia Aesthetics
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68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
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69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
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Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
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71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
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72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
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73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
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74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
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76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
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77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
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79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
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80
Cementation
Cementation
632018
81
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82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
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87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
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92
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93
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94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
2
Preparation Design
Retention form 25deg-8deg Resistance form Prepared tooth 4mm+ tall
Line of draw
07 mm - 20 mm All Ceramic15 mm - 20 mm PFMAbove images taken from Glidewell Laboratories
Preparation Design- Zirconia
Zirconia (1100mpa-1400mpa)
632018
3
Prep counter clockwise Less tissue damage (rotation is rolling on tissue) amp faster tooth reduction
Prep clockwise Tissue removal due to bur rotating opposite direction
rolling on tooth creates less reduction of tooth structure
Place a single cord after preparing interproximal area
bull Bur system that allows for easy depth reductionidentification
bull Retention 25deg-8deg (burs have 2deg-3deg)
bull Resistance form (boxgrooves)
bull Crown height (4mm+)
bull Reduction Variations
bull Full Gold (05mm+)
bull PFM (15-2mm)
bull All Ceramic
bull Lithium Disilicate
bull Zirconia 08mm
K0095 Preparation Kit (Brasseler USA)
Preparation Design
632018
4
Margin Refinement E-Statis Prep
(SciCan)
K0095 Preparation Kit (Brasseler USA)
Dent Mater 2008 Jul24(7)978-85 doi
101016jdental200711019 Epub 2008 Jan
15
Bond strength of self-etch adhesives to dentin
prepared with three different diamond burs
Ermis RB De Munck J Cardoso MV Coutinho
E Van Landuyt KL Poitevin A Lambrechts
P Van Meerbeek B
Oper Dent 2010 Nov-Dec35(6)624-33 doi
10234109-379-L
Effect of surface preparation on bond strength
of resin luting cements to dentin
Peerzada F Yiu CK Hiraishi N Tay FR King NM
Preparation DESIGNS-Burs
632018
5
Margin refinement with electric
handpiece 5-10000 rpms
Zirconium
Crowns
632018
6
Disposable Single Use Diamonds-medium or coarse grit
bull NeoDrys
bull NeoDiamonds
bull Bite-Check 18um
632018
7
Round end taper 1122811218
End Cutter 5014
Egg 1900
Modified Flap End Taper KR 08168
0512C1300F0710C 0116C0818C
Everyday Go To Minimally Invasive Burs
632018
8
Offer not valid for previous purchases or in conjunction with any other offer
Free Pack of NEODiamonds
NSK
NLZ Electric Handpieces
632018
9
Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
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94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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100
632018
101
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102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
3
Prep counter clockwise Less tissue damage (rotation is rolling on tissue) amp faster tooth reduction
Prep clockwise Tissue removal due to bur rotating opposite direction
rolling on tooth creates less reduction of tooth structure
Place a single cord after preparing interproximal area
bull Bur system that allows for easy depth reductionidentification
bull Retention 25deg-8deg (burs have 2deg-3deg)
bull Resistance form (boxgrooves)
bull Crown height (4mm+)
bull Reduction Variations
bull Full Gold (05mm+)
bull PFM (15-2mm)
bull All Ceramic
bull Lithium Disilicate
bull Zirconia 08mm
K0095 Preparation Kit (Brasseler USA)
Preparation Design
632018
4
Margin Refinement E-Statis Prep
(SciCan)
K0095 Preparation Kit (Brasseler USA)
Dent Mater 2008 Jul24(7)978-85 doi
101016jdental200711019 Epub 2008 Jan
15
Bond strength of self-etch adhesives to dentin
prepared with three different diamond burs
Ermis RB De Munck J Cardoso MV Coutinho
E Van Landuyt KL Poitevin A Lambrechts
P Van Meerbeek B
Oper Dent 2010 Nov-Dec35(6)624-33 doi
10234109-379-L
Effect of surface preparation on bond strength
of resin luting cements to dentin
Peerzada F Yiu CK Hiraishi N Tay FR King NM
Preparation DESIGNS-Burs
632018
5
Margin refinement with electric
handpiece 5-10000 rpms
Zirconium
Crowns
632018
6
Disposable Single Use Diamonds-medium or coarse grit
bull NeoDrys
bull NeoDiamonds
bull Bite-Check 18um
632018
7
Round end taper 1122811218
End Cutter 5014
Egg 1900
Modified Flap End Taper KR 08168
0512C1300F0710C 0116C0818C
Everyday Go To Minimally Invasive Burs
632018
8
Offer not valid for previous purchases or in conjunction with any other offer
Free Pack of NEODiamonds
NSK
NLZ Electric Handpieces
632018
9
Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
4
Margin Refinement E-Statis Prep
(SciCan)
K0095 Preparation Kit (Brasseler USA)
Dent Mater 2008 Jul24(7)978-85 doi
101016jdental200711019 Epub 2008 Jan
15
Bond strength of self-etch adhesives to dentin
prepared with three different diamond burs
Ermis RB De Munck J Cardoso MV Coutinho
E Van Landuyt KL Poitevin A Lambrechts
P Van Meerbeek B
Oper Dent 2010 Nov-Dec35(6)624-33 doi
10234109-379-L
Effect of surface preparation on bond strength
of resin luting cements to dentin
Peerzada F Yiu CK Hiraishi N Tay FR King NM
Preparation DESIGNS-Burs
632018
5
Margin refinement with electric
handpiece 5-10000 rpms
Zirconium
Crowns
632018
6
Disposable Single Use Diamonds-medium or coarse grit
bull NeoDrys
bull NeoDiamonds
bull Bite-Check 18um
632018
7
Round end taper 1122811218
End Cutter 5014
Egg 1900
Modified Flap End Taper KR 08168
0512C1300F0710C 0116C0818C
Everyday Go To Minimally Invasive Burs
632018
8
Offer not valid for previous purchases or in conjunction with any other offer
Free Pack of NEODiamonds
NSK
NLZ Electric Handpieces
632018
9
Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
5
Margin refinement with electric
handpiece 5-10000 rpms
Zirconium
Crowns
632018
6
Disposable Single Use Diamonds-medium or coarse grit
bull NeoDrys
bull NeoDiamonds
bull Bite-Check 18um
632018
7
Round end taper 1122811218
End Cutter 5014
Egg 1900
Modified Flap End Taper KR 08168
0512C1300F0710C 0116C0818C
Everyday Go To Minimally Invasive Burs
632018
8
Offer not valid for previous purchases or in conjunction with any other offer
Free Pack of NEODiamonds
NSK
NLZ Electric Handpieces
632018
9
Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
6
Disposable Single Use Diamonds-medium or coarse grit
bull NeoDrys
bull NeoDiamonds
bull Bite-Check 18um
632018
7
Round end taper 1122811218
End Cutter 5014
Egg 1900
Modified Flap End Taper KR 08168
0512C1300F0710C 0116C0818C
Everyday Go To Minimally Invasive Burs
632018
8
Offer not valid for previous purchases or in conjunction with any other offer
Free Pack of NEODiamonds
NSK
NLZ Electric Handpieces
632018
9
Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
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14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
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38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
7
Round end taper 1122811218
End Cutter 5014
Egg 1900
Modified Flap End Taper KR 08168
0512C1300F0710C 0116C0818C
Everyday Go To Minimally Invasive Burs
632018
8
Offer not valid for previous purchases or in conjunction with any other offer
Free Pack of NEODiamonds
NSK
NLZ Electric Handpieces
632018
9
Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
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120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
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123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
8
Offer not valid for previous purchases or in conjunction with any other offer
Free Pack of NEODiamonds
NSK
NLZ Electric Handpieces
632018
9
Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
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93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
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123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
9
Important Minimize tissue damage allows for less time utilized in managing bleeding
SF1LM (Komet)
Margin Refinement
Important Minimize tissue damage allows for less time utilized in managing bleeding
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
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Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
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92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
10
Important Minimize tissue damage allows for less time utilized in managing bleeding
TISSUE MANAGEMENThellip
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
11
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
FluidTissue Management
Superoxol Epinephrine
Ferric Sulfate
ViscoStat 20
Astringent 155
Aluminum Chloride Viscostat Clear 25
Expa-syl
Hemostasyl
Aluminum Sulfate
Tissue Goo 25
Various Cords
Enhancing Moisture Control
FluidTissue Management
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
12
FluidTissue Management
FluidTissue Management
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
13
Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
FluidTissue Management
A soft tissue laser incision at 1000x magnification
Laser cut
Superficial coagulation
Heat dissipation with littleno edema
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
14
Features
bull Number 1 dental laser in the world
bull More power ndash 3 watts 810nm
bull New easy to use presets
bull New treatment timers for perio
treatment
bull Wireless foot control
bull Optional battery pack
bull Perfect for first timers or hygienists
bull Affordable
bull Disposable tips or fibers
bull Certification included
bull MSRP $4495
bull CE Price $3495
Use code
CESNYDER18
Aesthetic Contouring
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
15
Aesthetic Contouring
Time
ROI
Aesthetic Contouring amp ExperTemp Provisional
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
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38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
16
AMD Picasso Laser Tissue re-contouring ExperTempamp Impression
Bite Registration
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
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123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
17
Verify bite Shimstock
Over Impression Preparation Bite Registration
Dead soft Delar Wax Firm Hard Bite Reg
Shimstock
Facebow Full Arch Impression Provisional Lab Articulation
Centric Occlusion DentistryExample
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
18
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
19
Parkell Accufilm II is 21microm for dentistry
Great Lakes articulating ribbon 12microm
8microm Almore Shimstock foil
8microm articulating paper
Shimstock amp Articulating Paper
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
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72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
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76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
20
TrollDental-8microm Articulating Paper
TIP
The range of PDL width 015mm ~ 038mm
bull Average PDL width by age
o 11 ~ 16 years old 021mm
o 32 ~ 52 years old 018mm
o 51 ~ 67 years old 015mma
bull The PDL width decreases with age
bull The PDL width is thinnest around the middle 13 of the root
Tooth with more function has bigger PDL space
PDL amp Occlusal Records
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
21
Bite Registration amp Occlusal IndexingTIP
Built in errorsThicknessRotation Rocking
Function amp Failures
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
22
Closed Bite Trays (most common)
Lack of rigidity may cause distortion
Spring back after impression potential
No cross arch stabilization
Thin spots or perforations can cause distortion
Impression material shrinks towards bulk
Unable to recreate excursive movements
Potential for errors amp adjustments extremely high
Impression Trays
Quad Tray Extreme (Clinicianrsquos Choice) amp Bite
Registration
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
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76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
23
PEER REVIEWED
The Catapult Group rated
the Quad-Tray Xtreme as
better than just as good
or tied with other available closed bite
trays
Quadrant amp Disposable articulators
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
24
Bite Registration Importance
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
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76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
25
Disposable Articulators
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
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Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
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76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
26
Semi Adjustable
not on Hinge Axis
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
27
Semi Adjustable
not on Hinge Axis
TRY-IN NO ADJUSTMENTShellip
A few steps makes
a big difference
Patients notice the
difference
Do you want to be
like everyone else
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
28
Key to adjustments Full Arch Impressions
Facebow
Bite Registration
Semi Adjustable Articulator
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
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Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
29
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
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82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
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92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
30
Ceramic Adjustment Jiffy Ceramic Polishers (Ultradent)
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
31
Occlusal RecordBite Registration
Fast Setting Rigid PVS
Or
Wax
MODEL ARTICULATION amp EQUILIBRATION
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
32
Incisal Pins
Selection Process
Open Bite Trays
Plastic-full or quadrant
Metal-full or quadrant
Custom Trays
Non-perforated or perforated (metal or plastic)
Rigidity can eliminate tray distortion and rebound
Spring back after impression is possible with plastic
Cross arch stabilization
Ideal occlusal stops for proper model articulation
Able to recreate excursive movements if mounted on a semi or fully adjustable articulator
Potential for errors amp adjustments are low
Impression Trays
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
33
Stock tray sizes
Impression Trays
Difficult for ideal fit
Impression Trays
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
34
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for all open bite
trays not just custom trays
Only negative is time
Impression Trays
Impression Trays
Custom trays create more ideal placement
Thinner material creates less distortion
USE TRAY ADHESIVES for
all open bite trays not just custom trays
Only negative is time
Selection Process
Custom Tray
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
35
4 upper amp lower trays
60 sec 158degF
Fast efficient
Virtually custom
30 less impression
material used
Impression Trays
HeatWave by Clinicianrsquos Choice
TIP
Measure on a model or in the mouth to determine size
of tray needed
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
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Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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Adhesion
Adhesion
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Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
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Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
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Cementation
Cementation
632018
81
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82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
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92
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632018
94
632018
95
632018
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Fast Systems
Bonded Adhesion
Increasing strength demands
632018
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ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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101
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102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
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105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
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123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
36
Trays are unique and fit very well with minimal adjustments typically being needed
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
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82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
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92
632018
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632018
94
632018
95
632018
96
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Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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100
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101
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102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
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119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
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123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
37
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
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123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
38
Impression Trays
Impression Trays
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
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123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
39
Impression Trays
Impression Trays
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
40
Make cases easy
Identium for multiple teeth
Make cases easy make your patients happy
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
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MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
41
Make cases easy make your patients happy
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
42
ULTRADENTrsquoS NEW THERMO CLONE VPS
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
43
Impression Materials
Still account for 85-90 of
the market
Types
Vinylpolysiloxanes
Polyethers
Vinylsiloxanether (VSXE)
Panasil Initial Contact (VPS)
Kettenbach
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
44
Panasil Initial Contact Lowest contact angle of any VPS impression
material
Fast set and Regular set
Best Value Materials Available
Kettenbach
Panasil Initial Contact vs Aquasil
Kettenbach
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
45
Cracked toothKettenbach
Panasil Initial ContactKettenbach
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
46
Panasil Initial ContactKettenbach
Kettenbach
Identium(Vinylsiloxanether-VSXE)
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
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Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
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Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
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75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
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97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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100
632018
101
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102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
47
Identium
Fast set and Regular set
Medium or Heavy viscosity
Light viscosity flow
Excellent flow ability
Exceptional hydrophilicity
Easy removal from mouth and model
Odorless and neutral taste
Can be poured immediately
Identium Scan is a new scanable Vinylsiloxanether that handles like a
polyether with a long working time amp snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials A-silicone and polyether Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORTreghellipvolume 5 Issue 3
Syringe Placement Dry all teeth in arch
Place tip in most difficult area first
Keep tip on margin and immersed in material
Go around entire margin first
Next go to adjacent teeth
Then do coronal aspect of teeth
Double Mix Single Impression is the most accurate
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
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94
632018
95
632018
96
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Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
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100
632018
101
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102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
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123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
48
Provisionals
bull Utilize an accurate preliminary over impression
bull Maintain over impression
bull Check contacts and occlusion
Provisionals
-Visalys (Kettenbach)
-Inspire (Clinicianrsquos Choice)
-Structure (VOCO)
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
49
Simplified Provisionals
Siltech Putty Matrix
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
50
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Duplicate waxup model in stone
Scribe a 05-1mm line with a sharp instrument into the
model where the tissue and tooth come together
Provisionals (Bead Line Technique)
Duplicate model with a fast setting polyvinyl impression material
I have used light and medium body washes with a heavy body tray
material
Provisionals (Bead Line Technique)
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
51
Provisionals (Bead Line Technique)
The scribed line creates the Bead Line in the over impression of the cast
The Bead Line in the over impression creates pressure along the tissue
and preparation margin This causes a thin cut or separation of the
acrylic flash from the provisionals for easier clean up
Provisionals (Bead Line Technique)
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
52
Typically the excess acrylic can be removed with fingers a spoon or discoid instrument Minimal
to no effort is required to remove excess flash If a void or a margin is exposed simply fill the
void with a flowable Etching and a bonding agent are not required as the flowable will adhere to
the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth
Provisionals (Bead Line Technique)
The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth
structure Typically the process takes 5-10 minutes to make provisionals Consepsis (Ultradent)
can be placed on the teeth and dried prior to fabricating provisionals
Provisionals (Bead Line Technique)
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
53
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinicianrsquos Choice)
-ExperTemp (Ultradent)
PROVISIONALS
Cling 2 (Clinicianrsquos Choice) for all my full crowns amp bridges retentive
inlays amp onlays
MY FAVORITE TEMPORARY CEMENTS
ClearTemp LC (Ultradent)
For either veneers or thin
anterior cosmetic restorations
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
54
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework amp questions
Post-Op Check
From Imaging amp Diagnostic Wax-up the entire case was duplicated
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
55
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
56
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
57
Bead Line Veneer Provisional Restorations Pract Proced Aesthet Dent 200921(3)E1-E7
Cosmetic Provisionals (Bead Line Technique)
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
58
Cosmetic Provisionals (Bead Line Technique)
Scribe a 05mm-1mm groove into tissue amp a little on tooth
Cosmetic Provisionals (Bead Line Technique)
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
59
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
No Polish Necessary if you use a good model
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
60
Cosmetic Provisionals (Bead Line Technique)
Cosmetic Provisionals (Bead Line Technique)
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
61
Cosmetic Provisionals (Bead Line Technique)
Indirect Restorations
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
62
Crown Classification
bull Lithium disilicatesilicate
bull IPS emax PressCAD Obsidian
bull High esthetics and strong
bull 360-400 MPa
bull Zirconia (high strength non-etchable)
bull Monolithic BruxZir LAVA Plus KDZ Bruxer OccluZir ZirLux FC
bull Fastest growing improved esthetics~1000 MPa
bull Zirconia supported IPS emax ZirPress ZirCAD LAVA DVS
bull High esthetics may be subject to chipping fractures slow cooling
bull Zirconia Multi-layered
bull CAP Multi-FZ
bull Katana HT ST UT
bull Translucency esthetic and strong
bull 557-699-1125 MPa
Indirect Restorations
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
Indirect Restorations
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
63
Zirconia Multi-layered
Zirconia Multi-layered
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
64
Zirconia Multi-layered
All-Ceramic Crowns
Zirconia Multi-layered
(557-1125mpa)
Anterior Crowns
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
65
31
38
43 44
37
0
10
20
30
40
50
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
()
High translucent for anterior restoration
The same level translucency as
glass ceramic (emax Press LT)
Wave length of
light 700nm
Thickness of
sample 05mm
LT (A1)ST (ST10) UT (UT10)HT (HT10) (T0)
Prettau Anterior
Tra
nslu
ce
ncy
Lithium
DisilicateMulti-Layer Zirconia
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
66
Thickness of
sample 12mm
Tra
nslu
ce
ncy
(⊿L(W-B))
0
5
10
15
20
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT Prettau Anterior
Multi-Layer Zirconia
LT (A1) (T0)
Prettau Anterior
ST (ST10) UT (UT10)HT (HT10)
High translucent for anterior restoration
Lithium
Disilicate
The same level translucency as
glass ceramic (emax Press LT)
Mechanical Properties
30 Increase Compared to Lithium Disilicate
ISO 68722008
(Three-point bending test)
Sample size 3 x 4 x 40 mm
Prettau Anterior 670mpa
Fra
ctu
ral s
tre
ng
th
1125
699
557
427
0
200
400
600
800
1000
1200
KATANA
Zirconia HT
KATANA
Zirconia ST
KATANA
Zirconia UT
emax Press LT
Multi-Layer Zirconia
LT (A1)Lithium
Disilicate
ST (ST10) UT (UT10)HT (HT10)
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
67
Zirconia Aesthetics
Zirconia Aesthetics
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
68
Zirconia Aesthetics
Traditional Resin CementationConventional methods applied to the bonding of
silica-based ceramics are not successful You cannot acid etch and silanate the intaglio surface of metal
oxide ceramics as you can with lithium disilicate
(emax) or other glass ceramic restorations
HF acid does not sufficiently alter the surfaces ofmetal oxide ceramics and conventional silane
coupling agents cannot provide chemical bonds to
these materials because of the lack of silica
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
69
Zirconia CasesShould be delivered from the lab having been
sandblasted with aluminum-oxide particles Research shows small particles (30 microm) low pressure (35 psi) to
enhance resin bonds while minimizing surface damage
Tribochemical silica coatingAlternative methods for bonding to metal alloys andmetal-oxide ceramics include tribochemical silicacoating and other silica-coating methods Thesemethods embed silica particles into the metalalloymetaloxide ceramic surfaces Silane couplingand bonding agents used for conventionalfeldspathic porcelain can then be used to bond tothe silica-modified surfaces (exRocatec Silicoating3MESPE)
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
70
Prior to Try-in
The internal surfaces should be coated
with a ceramicmetal primer that
contains adhesive monomers that
chemically bond to metal oxides
MDP has been shown to offer the most
consistent bonds to zirconia
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
71
MDP Monomer
Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
bull (Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
BONDS WITH OR WITHOUT HF
ACID ETCHING
THE ldquoNO-WATERrdquo SILANE w MDP
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
72
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers
A disadvantage of many other silane products is that they are pre-
hydrolyzed
Another disadvantage is some require the use of Hydrofluric Acid
etching and sometimes in addition to Micro-Etching The new
Monobond Plus requires HF and Micro-Etching as well as 60 minute
activation time period
Zirconia Cleaning Try-in contaminates
the surface more than if a ceramic primer is not present
Salvia contains phosphates so they compete for the same receptor sites as the ceramic primers
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
73
REVIEW Ceramic Try-in
Make sure it is sand blasted properly from lab
Use a Ceramic Primer prior to try-in (unless using Calcium Aluminate Cement)
Ultrasonic with ethanol after try-in
No additional MDP Ceramic Primer needs to be used
Or
Sandblast after try-in and use a MDP Ceramic Primer then follow cementation protocols
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
74
Enamel amp Variable Dentin Bonding
NEXT ProblemVarying tooth substrates
Maintain good retention and resistance preparation design
Cementation
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
75
Adhesion
Adhesion
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
76
Class I or II
Tooth Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treating
When bonding to enamel an etch amp rinse approach is definitely preferred indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel When bonding to dentin a mild self-etch approach is superior as it MDP involves (like with glass-ionomers) additional ionic bonding with residual HAp This additional primary chemical bonding definitely contributes to bond durability Altogether when bonding to both enamel and dentin selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009)doi101016jdental200911148
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
77
Restoration Placement Bonded
Margin placement Moisture Control Technique Sensitive Materials
Self Adhesives
Bonding agent (TE or SE) amp luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Cementation Material Options
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
78
Traditional Cementation Options
Glass Ionomers Resin Modified Glass Ionomers
Acidic pH
Moisture Tolerant
Fluoride Release
Degrades over time
Low bond strength
Biocompatibility-Fair
Bioactivity-None
Sealing Quality-Ok
Acidic pH
Insoluble
Moisture Tolerant
Fluoride Release
Stronger Than Traditional GIs
Degrades over time
Improved bond strength
Biocompatibility Ok
Bioactivity-None
Sealing Quality-Ok
Ceramic Primer on Restorations
Cement Selection
TRADITIONAL GLASS IONOMER
CEMENTATION OPTIONS
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
79
Resin Modified Glass Ionomer Cements
Use Ceramic Primer prior to try-in
Clean with ethanol after try-in
Keep tooth slightly moist and place RMGI cement
as it will chemically cure to the tooth and the Ceramic Primer
Still want to always have good prep design
Resin Modified Glass Ionomer
Cement and a Ceramic Primer Lab sandblasts 30psi w 50 micron aluminum-oxide
particles
G-Multi Primer (MDP) prior to tryin
Ultrasonic clean with ethanol
Place FujiCEM2 RMGI cement in restoration
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
80
Cementation
Cementation
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
81
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
82
Alkaline pH 85
Moisture Tolerant
Self Sealing
Apatite Formation
InsolubleNo Degredation
Stronger with time
Semi Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane conditioning bonding
Calcium AluminateGlass Ionomer Hybrid Cement
TIP
Ceramir Crown amp Bridge is indicated for permanent cementation of
bull Porcelain fused to metal crowns and bridges
bull Metal (gold etc) crowns and bridges
bull Gold inlays and onlays
bull Cast or prefabricated metal posts
bull Strengthened core all-zirconia or all-alumina
ceramic crowns and bridges
bull Lithium Disilicate (eMax)
bull Stainless steel crowns
bull Ortho bands and appliances
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
83
Bioactivity
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH
Calcium AluminateGlass Ionomer Hybrid Cement
Cementation Technique
Mix for 8-10 seconds
17ml vs single cap 10ml
3-4 restorations
Calcium AluminateGlass Ionomer Hybrid Cement
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
84
Ceramir CampB Comparison to other
cement classes
Lithium Disillicate (eMax)bull Cleaning
wphosphate scavengers is not necessary
bull Silane is
contraindicated
bull Tooth etching or conditioning is not necessary
bull Bonding agent is not needed
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
85
CEMENTATION TECHNIQUE
Zirconia Restorations- Cleaning w phosphate
scavengers is not necessary
- Silane is contraindicated
- Tooth etching or conditioning
is not necessary- No bonding agent necessary
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
86
Cement Selection
Crown RetentionResults Zirconia crowns (KgF)
Material Result (Zirconia crowns) KgF
Ceramir Crown amp Bridge 321 plusmn 63
RelyX Unicem (3M) 278 plusmn 113
Dyract Cem (Dentsply) 122 plusmn 31
Rely X Luting (3M) 109 plusmn 65
0
5
10
15
20
25
30
35
Ceramir Crown amp
Bridge
RelyX Unicem (3M) Dyract Cem
(Dentsply)
Rely X Luting (3M)
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
87
Cement Selection
Three year recall data yielded no loss of retention no secondary caries no marginal discoloration and no
subjective sensitivity All restorations rated excellent for marginal integrity
Cement SelectionJournal of Esthetic amp Restorative Dentistry March 2015
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
88
Simplify Cementation
-Silane is contraindicated
-Restoration does not have to be cleaned after tryin
-Tooth etching or
conditioning is not necessary
-Bonding agent is not needed
Technique ResearchLiterature
Moisture Tolerant
No Sensitivity
Alkaline pH
Apatite Forming
Insoluble
Stronger With Time
Self Sealing
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
89
What do you cement with
Weigh the benefit
of a bioactive
cement vs a bonding agent amp
adhesive cement
Evaluate the preparation design
amp moisture control
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
90
Missing Canine
Zirconia abutment and Empress crown
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
91
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
92
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
93
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
94
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
95
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
96
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
97
Fast Systems
Bonded Adhesion
Increasing strength demands
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
98
ResinCement Options
Self Adhesive Resin AcidicNeutral pH
Not moisture tolerant
Low-moderate initial bond strengths
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Ok
Bonding Agent w Resin AcidicNeutral pH
Not moisture tolerant
Best initial bond strengths but can decreases wtime
Decreased bond strength over time
Water sorption
Biocompatibility-Ok
Bioactivity-None
Sealing Quality-Good but technique sensitive
SE Resin Cements
Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less
bull Wettability
bull Which Results in Less Contact to the Tooth
bull Which May Result in a Less Durable Bond
bull Acid Neutralization
bull Prolonged Gel State
bull Convenience
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
99
All Ceramic Crown Microleakage
Bonded Resin Cement SE Auto Resins
After simulated aging through cyclic loading (12 million) and dye penetration test to
detect Microleakage LSU Dental School IADR 2006 Abstract 2090
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
100
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
101
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
102
Results amp Conclusions
Activa (Pulpdent)
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
103
Activa (Pulpdent)
Activa (Pulpdent)
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
104
Activa (Pulpdent)
Theracem (Bisco)
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
105
Theracem (Bisco)
New ldquoUniversalrdquo Systems
Simple amp easy to use
Direct amp indirect techniques
Use as Total Selective or Self Etch
Low sensitivity
Lots of MDP Based Products
MUST use manufacturers bonding
agent and their dual cure resin
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
106
Originally Developed by Kuraray 1983
bull Acidic Monomer Activates Silanes amp Chemically Bonds to Metal Oxide Ceramics (Zirconia amp Alumina)
(Key Ingredient to make a Silane Universal)
bull Hydrophilic amp Hydrophobic
bull Very Durable Dentin Bond
(Creates An Insoluble calcium Salt with Dentin)
bull Is The Most Copied Monomer In Dentistry
bull The Most Researched Monomer In Dentistry
bull 20 + Years Of Research On Metal Oxide Ceramics (Zirconia amp Alumina)
bull Strongest amp Most Durable Bond to Metal Oxide (Zirconia amp Alumina) Ceramics
MDP Adhesion Monomer
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
107
LITHIUM DISILICATE amp SILICATE LEUCITE AND FELDSPATHIC
RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE
EFFICIENT AND HIGHLY
EFFECTIVE
httpswwwncbinlmnihgovpmcarticlesPMC3148178
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an
average replacement time of 57 years due to secondary caries precipitated by bond failurerdquo
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
108
Factors that compromise bond durability in restorative dentistry
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
BOND LOCATIONamp DEGRADATION
bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Degrease in Bond Strengths with most
bonding systems
Factors that compromise bond durability in restorative dentistry
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
109
Bond Degredation
Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66
Resin-dentin bonds are not as durable as was
previously thought Microtensile bond strengths often
fall 30 to 40 in 6 to 12 months
Cement Selection
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially
disappeared after 6 months of intraoral function
Instability of hybrid layersproblem may be more severe than we realize
Factors that compromise bond durability in restorative dentistry
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
110
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al (2007)Mazzoni et al (2007)
Factors that compromise bond durability in restorative dentistry
Courtesy Pacific University (Dr Marc Geissberger)
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
111
InstroN Ultra Tester (Ultradent)
Ultra Jig (Ultadent)
MaximumMinimum Shear Bond Strength
per Bonding Material
Shear Bond Test Results - 2012
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
112
Zirconia Try-in Questions The lab should have sandblasted the restoration at 30-50psi w
50 micron aluminum oxide
After try-in
Ivoclean and silanate
Ultrasonic with ethanol after try-in or steam clean then silanate
Sand blast then ultrasonic and ethanol
Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
Silanes
Universal Adhesives (wMDP)
Silane Primer + MDP
Organo-Phosphate Monomer (MDP)
Silane Primers A disadvantage of many other silane products is that they are pre-hydrolyzed Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching The new Monobond Plus requires
HF and Micro-Etching as well as 60 minute activation time period
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
113
What substrate are we treating
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding
30 Decrease in Bond Strengths with most
bonding systems
What do you use
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
114
FULL COVERAGE CERAMICS AND ZIRCONIA
Blatz MB et al JPD 2003
Al-Amleh B et al J Oral Rehabil 2010
Wolfart M et al Dent Mater 2007
Edelhoff D Ozcan M Clin Oral Implants Res
2007
Papia E et al J Biomed Mater Res 2013
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
115
Zirconia Ceramic Conditioning
bull Primer was applied
on Zr surface
bull Ultrasonicated in ethanol to remove unreacted resin components 00
200
400
600
800
NP AZ ZP MP CC SBU ABU
Pure
ZrPrimer
Silane
ZrPrime
r
Silane
ZrPrimer
Adhesive
ZrPrimer
Adhesive
LC required
Contact Angle as
Zr Primer
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
116
0
5
10
15
20
MDPKuraray
MDPPCM
MDPDMI
24hr
TC100000
Bond durability of phosphate monomers with different purity Okayama Univ (Yoshihara K et al)
The 33rd Meeting of the Japanese Society for Adhesive Dentistry 2014 P-7
Primer15 MDP solutionBond Same BondComposite Same
Micro tensile bond strength to Dentin
(MPa
)ldquoMDPrdquos perform differently
MDP-containing material bonds to Zirconia
CLEARFILtrade CERAMIC PRIMER
MDP
γ-MPS
Ethanol
247
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
117
Zirconia Cementation Review Silanate with Clearfil Ceramic Primer prior to tryin
Clean with ethanol or steam clean then reapply ClearfilCeramic Primer
Difficult Isolation use
Resin modified glass ionomer (Use silane)
Ceramir (Do not silanate)
Good isolation with moderate to good resistance amp retention
Silane
SE Resin cement such as Panavia SA Plus Or GC LinkAce
Good isolation with poor to moderate resistance amp retention Silane
Resin adhesive and bonding agent
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
118
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
119
Sand Blaster
Ceramic Primer (MDP)
Resin
Universal
Zirconia
EtchedSelf Etch
1 Prepare Restoration Surface
Sand Blaster 30um 35psi2 Ceramic Primer (MDP)
3 Etch Enamel 15-30 secs Etch Dentin 10-15 secs
4 Apply Adhesive Apply into preparation X secs Thin with air X secs Light Cure
5 Seat Restoration Load cement into restoration Seat amp remove Most excess(Air inhibiting liquid) Light cure
Bonded Adhesion
Bonded Adhesion
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
120
bull More efficient than Halogens
bull Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
bull Longer lasting Cordless Batteries
bull Faster curing (5 seconds)
bull Smaller in sizelighter
bull Less heat
Benefits of LED Lights
Comparisons - Lights
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
121
VALO delivers
Access to the curing site = Energy to the resin
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
122
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
123
Machined from Aerospace Aluminum
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
124
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
125
Design
Power
Durability
Access
Posterior tooth
Broad Light Output Range
395-480nm
Cost
Weight
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
126
Bonded Adhesion
Bonded Adhesion
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
632018
127
Review Air abrasion by lab
Use a Ceramic Primer prior to try in of ceramics
Pick from the Zirconia Cleaning Steps
Cementation
High bonds to enamel and dentin with an adhesive and dual cure resin cement
Use Glass Ionomer or Calcium Aluminate in Moisture Challenged areas and or high caries risk when adequate tooth retention is available
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