SUC-University of Delware-Aug2017bestdentalce.com/yahoo_site_admin/assets/docs/SUC... · A typical single-unit crown and bridge procedure requires two appointments to complete (exception

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Insights for every step!

The Keys to a… Successful, Predictable, and Efficient Single-Unit Crown Procedure

Jason H. Goodchild, [email protected]

Clinical Education Manager, North America

Dentsply Sirona Restorative

Associate Prof & Chair. Dept of Diagnostic Sciences

Creighton Univ. School of Dentistry

Introduction

[email protected]

From Philadelphia, PA

Private Practice (Havertown, PA)

EducationUniv. of Pennsylvania School of Dental Medicine Dept. of Oral Medicine

Creighton University School of Dentistry Chairman, Dept. of Diagnostic Sciences

Dentsply Sirona Restorative

I promise to tell the truth . . .

“Success is not an accident!”~ Tony Robbins

“Success in dentistry is mainly dependent on doing

the basics well”~Anonymous

Goodchild’s Definition of Efficiency in Dentistry

Working quickly AND

Getting it done right the first time

The Dental Solutions Company

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No Post-op

sensitivity

Low film thickness

Cavity adaptation

Bulk fill w/ 3 year clinicalsRadiopaque

Low stress – reduced microleakage

Preferred Handling

Simplified Shading

Radiopaque

Dependable Cure

Smooth surface

One component

Dentsply SironaClass II Solution

Predictable Tight Contacts

Isolation

Less flash, less finishing

Class II Success!Dependable.

Simple.Efficient.

Complex Class IIAnesthesiaPreparationCaries RemovalEtching?IsolationAdhesionMaterial PlacementLight CuringOcclusionFinishing / Polishing

BEFORE

AFTER

The Right Drug for the Right Procedure

Average Durations of Local Anesthesia after Intraoral Injection (mins)

Maxillary Infiltration Inferior Alveolar Block

Pulpal Soft Tissue Pulpal Soft Tissue

2% Lidocaine w/ 1:100K or 1:50k epi 60 170 85 190

3% Mepivacaine 25 90 40 165

4% Prilocaine 20 105 55 190

4% Prilocaine w/ 1:200k epi 60 150 75 180

4% Articaine w/ 1:100k or 1:200k epi 60 170 90 220

0.5% Bupivacaine w/ 1:200k epi 40 340 240 440

Local Anesthetic Maximum Dosages

Local Anesthetic Maximum Dose# of Carpules

Adult # of Carpules

50 lb Child

Lidocaine w/ 1:100k epi (2%-36 mg)Lidocaine w/ 1:50k epiLidocaine w/o epi

3.3 mg/lb (500 mg) 3.3 mg/lb (500 mg)2.0 mg/lb (300 mg)

13.8*5.58.3

4.6NR2.8

Mepivacaine (3% - 54 mg)Mepivacaine (2% w/ 1:20k levo)

2.6 mg/lb (400 mg)7.411.1

2.53.7

Prilocaine plain (4% - 72 mg)Prilocaine w/ 1:200k epi

4.0 mg/lb (600 mg) 8.38.3

2.82.8

Bupivacaine (0.5% - 9mg) 0.6 mg/lb (90 mg) 10 NR

Articaine (4% - 72 mg) 3.3 mg/lb (500mg) 6.9 2.3

Dent Clin N Am 2010;54:587–599.*Maximum dose of epinephrine in healthy patients is 0.2mg, accounting for epinephrine the maximum dose of lidocaine w/1:100k epi is 11 cartridges.

U.S. Retail Market Share ‐ Injectables

Injectable local anesthetics was a $159 million market in 2014 (9% ↑ from 2013)

By far the two biggest players, by molecule, are Lidocaine and Articaine

Since 2011, Articaine has surpassed Lidocaine as the revenue leader in the US

In 2014, Lidocaine was the units leader

Source: ADA, SDM

U.S. Retail Market Share ‐ Injectables

Source: ADA, SDM2014

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Articaine (1:100,000 or 1:200,000)

4% Articadent DENTAL (Articaine

HCl and epinephrine) 1:100,000 OR

1:200,000

Newest Molecule in US – Fastest Growing

Dominated by Septocaine (Septodont)

Strength: 4%

Only available with Epinephrine

Intermediate to Long Duration

Replacing Lidocaine – Works Better!

Pregnancy Category C

Articaine

Why is Articaine overtaking Lidocaine as the most commonly used local anesthetic molecule?

The answer is easy… It works better!

Dentists think it works better, and current literature supports it!

Articaine Controversy

Articaine important dates:11969: Developed in GermanyEntered clinical use1976: Germany1983: Canada1998: United Kingdom2000: United States2005: Australia

Haas & Lennon – first reports about possible link between 4% solutions and nerve injury (ie, articaine and prilocaine)2

1. Malamed SF. Articaine 30 years later. Oral Health. Feb 20162. J Can Dent Assoc 1995 Apr;61(4):319‐30.

The study revealed a higher then expected frequency of paresthesia following the use of articaine and prilocaine1

A follow-up study by Haas in 2009 also found a higher then normal frequency of nerve injuries for articaine during a 10-year period (1999-2008)2

Articaine: 109Lidocaine: 23Prilocaine: 29Multiple agents: 15

1. J Can Dent Assoc 1995 Apr;61(4):319‐30.2. J Can Dent Assoc 2009 Oct;75(8):579a‐f.

Articaine Controversy

Incidence of Paresthesia?

1:42 (US FDA, Septodont NDA 120-971, 1998)1:160,571 (JADA 2000;131:901-7.)1:140,000 (Tandlaegebladet 2005;109:10.)1:609,000 (JCDA 2009;75(8):579a-f.)1:785,000 (JCDA 1995;61:319-30.)1:3,200,200 (ZWR 2000;109(12):678–81.)1:3,700,000 (CRA Newsletter 2001;25(6):1–2.)1:4,159,848 (JADA 2010;141:836–44.)1:13.3 million - (Oral Health Group, Feb 2015)

1:700,000 Still not convinced?

What does Dr. Malamed have to say on this issue?

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Dimensional Stability

AccurateStrong

Strong & Flexible

AccurateEase of Use

Precision PlacementWork Time Safeguard

Time Savings

Easy Removal & Clean UpLow Film Thickness

Low Film Thickness

No Sensitivity;

Shade StabilityStrong

Dentsply SironaSingle-Unit C&B Solution

C&B Success!Dependable.

Simple.Efficient.

Dimensional Stability

Accurate

Strong

Strong & Flexible

AccurateEase of Use

Precision Placement

Work Time Safeguard

Time Savings

Easy Removal & Clean Up

Low Film Thickness

Low Film Thickness

No Sensitivity;

Shade StabilityStrong

Dentsply SironaSingle-Unit C&B Solution

C&B Success!Dependable.

Simple.Efficient.

Indirect Restoratives: The Single-Unit Crown Solution

Patient prepProvisional matrix impressionAnesthesiaTooth preparationTissue management ImpressionProvisionalizationCementation of provisional

Fixed Prosthodontic Landscape

A typical single-unit crown and bridge procedure requires two appointments to complete (exception is the CAD-CAM dentist)

Remove provisional crown and residual cement (anesthesia)

Fit and occlusal adjustment of permanent crown

Final cementation, clean excess cement

The Dental Solutions Company

Success is the result of proper

completion of the procedural

steps

The Class II & Single-Unit Crown

solutions involve products designed

to work together flawlessly

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Definitive Cementation ofFinal Restoration

Opportunity to Educate Around Pain Points

Clinical Pain Points

• Direct vs. Indirect Restorations?• The most important factor is the size of the lesion & destruction of tooth structure1

• Clinicians should determine:• Should the remaining tooth structure gain strength and protection from the

restoration?2

• If so, then think indirect restoration!

1. Schillingburg HT. Treatment Planning for Single-Tooth Restorations. In: Fundamentals of Fixed Prosthodontics. 4th Ed. 2012. p71–79.

2. International Dentistry 2001;1(1):70–80.

• Additional factors that necessitate the need for an indirect restoration:• large failing existing restorations (greater than one-half of the buco-lingual

intercuspal distance posteriorly) • cracks (symptomatic and possibly asymptomatic) • endodontically treated teeth • cuspal fracture• esthetics

JADA 2007;138:101–103.

Clinical Pain Points

Case Example…

Don’t forget good communication skills!

What about this case? A single central incisor?

“If it isn’t presented it can’t get done.”

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If it isn’t presented it can’t get done.”

What about this case? A single central incisor?

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Opportunities to Educate Around Errors


Why? Gives us an opportunity to see what we are doingSo, we can improve techniques and hopefully outcomesAnd encourage practitioners to more critically reevaluate their work

Lab Error!

Dentist Error!

The Single-Unit Crown Procedure

Provisional Impression

Final Impression

Provisional Crown

Provisional Cementation

Definitive Cementation

What are the consequences of getting these steps wrong?

Inaccurate provisional, poor margins, tissue irritation, added time

Inaccurate master model/die, inadequate final crown, added time

Inaccurate provisional, poor margins, tissue irritation, added time

Premature dislodgement, post‐op sensitivity, added time

Crown failure, tissue irritation, added time


Voids at or below the finish lines Indistinct and irregular finish lines

Create linear and clearly-defined finish lines

Avoid the J-shape or ski jump


Rough preparations with voids Voids at/near the finish line Short and irregular preparations

Create smooth and well-defined preparations Critically evaluate impressions for voids (avoid “the lab will just block that out”) Use buildups to avoid irregular anatomy, fill in voids, and increase retention

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Crown preparations must end on tooth!Remember the “Ferrule”

Remember the minimum height of prepsCement is doing all the work!

What about the “Ferrule Effect”

“Circumferential Banding Effect”

1.5-2mm

Making crowns that are not too high

Literature review…The biggest factors seem to be related to

inaccurate reproduction of the occlusal relationshipPhysical deformation of the mandible

during eccentric or opening movements1,2

Physical displacement of teeth under an occlusal load1,2

Inaccurate counter models3

Inaccurate Interocclusal recordStorage time and temperature4,5

461. Gen Dent 2000;48(1):86-91.2. J Prosthet Dent 1975;34:491-5.3. JADA 2006;137:96-98.

4. JADA 1998;129:1014-21.5. J Appl Oral Sci. 2007;15(3):195-8

Back to Basics

The Preparation

The Fundamental Aim of Tooth Preparation

...transform the tooth by a planned process

...to a uniformly reduced geometrical form

...with a closely defined finish line

...permitting sufficient space for the planned restoration

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Frequently encountered errors in toothpreparations for crowns

Inadequate tooth reduction on incisal or occlusal surfacesInadequate tooth reduction of the axial wallsOver-reductionExcess taperInadequate buildupsIndistinct marginsExcess gingival extensionUndercuts in the axial wallsSharp angles on the preparation

50JADA 2007;138:1373-5.

Three Most Important Factors to Consider:

Dent Clin N Am 2004;48:359-385.

1.Taper

2.Height

3.Reduction

Three most important factors…Taper, Height, Reduction

Dent Clin N Am 2004;48:359-385.

Significant retention from prepNO retention from prep

Creating a Naturally Retentive Preparation

Crown Preparation-Reduction and Margin Tooth Preparation Matches Crown Substrate

•Match crown preparation to material substrate!•Substrates have different preparation requirements

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Preparation Reduction Requirements by Substrate Zirconia PFM All-Ceramic

Only differences between PFM and Zirconia preps –

amount of reduction!

Minimum reduction for strength = 0.5mm

…..practical goal ~ 1mm+

(Celtra,eMax)

Another Case Example…

Pre-operative presentation. Concerned about the discoloration on #8.

Root canal therapy is completed. Preparation of tooth #8 is completed. Note dark color of the stump.

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Final impression of tooth #8. Completed layered zirconia crown on tooth #8 immediately after insertion.

Excellent preparation design captured by an excellent final

impression gives the laboratory technician the opportunity to create

beautiful esthetics!

Excellent preparation design gives the laboratory technician the opportunity to create beautiful esthetics!

Another Big Case…

49 year-old female who lost #12 because of a fractured root. Has been wearing a chairside provisional 11-13 for last six months.

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She is has been hesitant to finalize the bridge, up to this point you don’t know why

One day, she comes in and asks, “Do you think porcelain veneers can make my smile look better?”

We did an esthetic wax-up, and together with the patient decided on the “look” The patient chose porcelain veneers on 6-10, and a zirconia 3-unit FPD 11-13

Singlue-unit provisional 6-13 using Integrity Multi-Cure, from wax-up Provisional in-place. She actually started to really like it after 1-2 weeks!?!

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One week after final cementation, adjusted occlusion. Pt ecstatic about results! One week after final cementation, adjusted occlusion. Pt ecstatic about results!

Back to Basics

Final Impressions

US Final Impression Material Market Overview Work Time Characteristics of PVS vs PE

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“Success in dentistry is mainly dependent on doing the basics well” Let’s Define

and Re-define impression

making

Definition: An unequivocal negative likeness or copy in reverse of the surface of an object, an imprint of the

teeth and adjacent structures

Source: Glossary of Prosthodontic Terms, 2013.

Dental Impressions




Dental Impressions




Dental Impressions




Dental Impressions

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Dental Impressions It was reported that 89% of impressions had 1 or more observable errors!

Source: J Prosthet Dent 2005;94(2):112‐7.

Source: J Prosthet Dent 2005;94:112‐7.

What were the errors?

Source: J Prosthet Dent 2005;94(2):112‐7.

Number of different errors?

From Clinicians Report…

“Impression materials can no longer be indicted for restoration inaccuracies… Excellent impressions are most likely

achieved when clinicians are confident in their impression material and provide

adequate gingival retraction.”

July 2014

Tray Design and Viscosity Selection

Support for the material has to come from the tray or from the material itself!!!

The less supportive the tray is….the more stiff the material needs to be

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Tray Design and Viscosity Selection

Triple trays need material to provide support

Full arch/custom trays provide necessary support

• Seat the tray without impression material and instruct patient how to close into a normal bite

• Pay attention when recording a bite record unilaterally as the patient may go into lateral excursion on that side

• Instruct patient that once the tray is seated they should refrain from any movements of the tray thereby to minimize distorting the impression material at a critical phase during its set

Practice Seating the Tray!

Is there a difference in accuracy between triple trays (closed bite) and stock/custom trays (closed trays)?

Compared the die accuracy of:1

Complete arch heavy body Double-arch plastic tray heavy body Double-arch metal tray heavy body Double-arch plastic tray putty

Pros & cons of each!2

Tray flexure Differing viscosities Not appropriate for all cases Bite registrations3

951. J Prosthet Dent 2002;87:510-515.2. Gen Dent 2000;48(1):86-91.3. J Prosthet Dent 1975;34:491-5.

Impression Materials Range of Options

•Multiple viscosity options• XLV, LV, Monophase, Heavy, Rigid, Putty

•Set time options• Super Fast, Fast, Regular, Extra

What is each material best for?

Patient Experience?

97Photo courtesy of Parrish King, DMD

Criteria for Closed-bite tray

INDICATIONS1-2 prepared teethTray will fit behind the tuberosity

without impinging on the tissueClass I or II occlusionPrepared tooth has sound adjacent

teeth on each sideNatural occlusal stops

CONTRAINDICATIONSMore than 2 prepared teeth Insufficient occlusal reductionMost distal tooth in the archClass III occlusion Inadequate space for the tray

posterior to the tuberosityNo natural occlusal stops

Gen Dent 2000;48(1):86-91.

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Matching Viscosity Selection to Tray Choice• Support facilitates accuracy

Work Time and Set Time Issues• Faster isn’t always better

Delivery Options are Imperfect• What are the tradeoffs?

1-Step Dual Viscosity Impressionwith Christensen “Blowing Technique”

Video

Confidential – FOR INTERNAL USE ONLY

Hemostasis must be achieved to record an impression with accurate detail.

Impact of Ferric Sulfate?

Tray selection and seating are responsible for this example

Stock trays are not always the answer, tray size and proper seating are critical

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Movement during seating can cause drags in similar

locations

Movement during seating can cause drags in similar

locations

Really?!?

Seating errors will distort the impression

Goodoccluding contacts evident

Badneed to have more contact on adjacent teeth

Take closed bite impression and shine it to the light.

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There are multiple errors on this impression… contact with the tray and loss of marginal detail. Tray selection, tray

seating, or position errors could be the cause

If the patient is biting on the tray during the making of the impression there will be distortion, in this case the occlusion

will be incorrect

Not enough tray material to support the wash material is the problem here, also cotton rolls should be removed from

impression for disinfection purposes

Gross!!! The lab can distort the impression trying to remove these before pouring

Problems with relines and additions Problems with relines and additions

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Problems with relines and additions Problems with relines and additions

Was the wash material syringed into a saliva- or blood-filled sulcus? Fluid control is critical to capturing all the marginal

details

Syringing technique is responsible for this V-shaped defect. Likely caused by

starting/stopping in the same location

Material selection?? Viscosity selection??

Note the voids at approximately the same location on both preps…syringing of wash should not begin/end at the same location. Go around twice, and end at a different location

then wear you began.

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Making sure the margins are marked…

Aquasil XLV Impression

Tear Strength?!?

Importance of Tear Strength

Tear strength measures the resistance to fracture of a material subjected to a tensile force acting perpendicular to a surface flaw

High tear strength is necessary to ensure material retrieval from the sulcus, to allow for multiple pours of the model and to maintain the

accuracy of the impression!

Increased use of retraction pastes leads to less sulcular opening, thinner films in place and therefore the need for a stronger material

Intraoral Tear Strength• What is it?

• Tear strength of material while in thin cross-sections and when being removed from the mouth

• How is it measured?• A notched specimen is torn at MRT +90” (fastest measure

has ever been done) and material strength is measured

• How is test different than what is on market?• Competitors measure tear strength in thick pieces many

minutes after material sets. Since impression material gets stronger over time, this creates a false measurement for clinicians who want performance at MRT and not 15’ later.

• Why does new test matter?• Tears remain a leading error in impressions. A material

needs to be strong when removed from the mouth. Clinicians should know the clinical/intraoral tear strength of their material.

Intraoral Tear StrengthWhat is it? Tear strength of material while in thin cross-sections and

when being removed from the mouth

How is it measured? A notched specimen is torn at MRT +90” (fastest measure


How is test different than what is on market? Competitors measure tear strength in thick pieces many


Why does new test matter? Tears remain a leading error in impressions. A material


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Importance of Tear Strength

•Material placed into the sulcus, natural anatomic undercuts and flaws must be retrieved in one piece

•Time consuming and annoying to go back in and retrieve pieces left behind

•Timing is a critical component - retrieve at MRT not before

The Importance of Tear Strength

Source: J Esthet Restor Dent 2008;20:186-194.

Tissue Management defined: combination of hemostasis and fluid control, with displacement of tissue to allow for sufficient impression material placement

Source: Glossary of Prosthodontic Terms, 2013

How is hemostasis achieved?

Hemostasis: The stopping of blood flowVasoconstriction: Narrowing of blood vessels

Chemotherapy racemic epinephrine aluminum chloride ferric sulfate alum (potassium aluminum sulfate) aluminum acetate zinc chloride

J Prosthet Dent 2009;101:153‐157

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Alternative Category to Traditional Mechanical Retraction: Paste/Putty Chemical Retraction

Additional overhead/consumables costs Performs adequately for hemostasis and fluid control but

may underperform for retractionSome manufacturer’s instructions indicate product may work

better in conjunction with cordActive compound in majority of products is Aluminum

ChlorideWill require dwell time, and requires aggressive water rinsing

What is the purpose of Retraction?Create access for the wash material so that it can be placed into the desired area in a thick enough

volume so that it can be retrieved in one piece

“Modern Day” Retraction Techniques

Retraction Paste

Cord Placement

vs.

It is well known that placing cord creates an acute tissue injury that in some cases can

lead to post-operative discomfort, inflammation, and

marginal recession.

J Prosthodont 2006;15(2):108-12.

Gingival Retraction Cord

Causes local inflammation and acute tissue injury1

Can be associated with gingival recession2

May require additional anesthesiaOver 125 varieties on the marketCan be knitted, braided, or twistedCan be plain or impregnated

1. J Prosthodont 2006;15(2):108-12.2. J Prosthet Dent 1980;44(5):508-14.

Placing Retraction Cord

Use gentle pressure Will be traumatic to tissue Could be responsible for post-operative pain Tissue deflection! Obtain a V-Shaped sulcus Top of cord should be visible

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Print Ads Intraoral HydrophilicityA side-by-side vs. 3M (video files)

Impregum Garant Soft LB Imprint 3 Quick Step LB Aquasil® Ultra+ XLV FSImprint 4 Light

Test Method: Contact angle measured @2” @80% Relative Humidity on uncured impression material.Impregum, Imprint 3, and Imprint 4 are not registered trademarks of Dentsply Sirona.

*Date on File**As per stated in manufacturers’ DFU-Not tested or not stated in manufacturers’ DFUCompetitive brand names are not the property of DENTSPLY International.

Product Intraoral Hydrophilicity/ Uncured Film (2” @80% RH)

Set Hydrophilicity/ Cured Film (5” @50% RH)

Intraoral Tear Strength (.245mm)

24hr Tear Strength(.245mm)

Work w/Moist Prep*

Stated Intraoral Work Time**

Easy to Use Precision Delivery Option

Aquasil® Ultra+ 15° 5° 607 678 Yes 35” Yes

Imprint 4 19° 6° 441 539 No 35” No

Take 1 Advanced 72° 88° 196 338 No - Yes

Exafast 68° 66° 242 273 No - No

Flexitime 55° 58° 291 399 No 30” No

Imprint 3 70° 43° 505 614 No 40” No

Impregum 49° 54° 165 259 No - No

Panasil 16° 6° 334 366 No - No

Competitive Performance*Aquasil® Ultra+ material stands out across all areas to deliver clinical results in even the most challenging circumstances

Temporary vs. Provisional

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Provisional or Temporary Restorations

…In dental school I was taught……

“Don’t make the temporary too nice or the patient may not come back for the final crown!”

Considerations for Provisional Restorations

• Convenient Handling • Biocompatibility• Dimensionally Stable• Easy to Contour and Polish• Strong• Wear Resistant• Esthetic

Material Requirements

Selecting the Provisional Material

Methacrylates(poly) methyl(poly) ethylVinyl methylEthyl methyl

CompositesBIS-AcrylBIS-GMA ResinsUDMA

Light Curing the Provisional?

Let the material set for 90 seconds in the mouth then remove and command set with 20 seconds of light curing

Types of Provisional Cements

Resin-Based containing di-urethane di-methacrylate TNE (Temrex)Temp Bond Clear (Kerr)

Zinc Oxide EugenolTempBond (Kerr)

Zinc Oxide NonEugenolTempGrip (Dentsply Sirona)Tempbond NE (Kerr)

Zinc PolycarboxylateDurelon w or w/o vaseline

Removal of Provisional Cement

Designed to be different!

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Case Example

All Indirect Restorations Must Be Cemented!

The Confusing Landscape of Cementation

Definitive CementsHistory of Definitive Cements

• Oxychloride/Oxysulfate Cements (pre-1870)• Zinc Phosphate Cement (1870)• Silicate Cement (1873)• Zinc Oxide Eugenol Cement (1875)• Zinc Polycarboxylate Cement (1963)• Glass Ionomer Cement (1972)• Adhesive Resin Cement (1986)• Resin-Modified Glass Ionomer Cement (1992)• Self-Adhesive Resin Cement (2004)

1. Albers HF. Tooth-colored restoratives: principles and techniques. 9th Ed. BC Decker. 2001. p43-45.2. Pameijer CH. A Review of Luting Agents. Int J Dent 2012.

Milford News, c. 1929

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The 4 Major DefinitiveCement Categories

Glass Ionomer

Fuji I (GC)Ketac CEM (3M

ESPE)Ceramir (DOXA)

Resin-Modified Glass Ionomer

Rely-X Luting Plus (3M ESPE)FujiCEM Automix

(GC)Fuji Plus (GC)

Self-Adhesive Resin

Rely-X Unicem(3M ESPE)

Maxcem Elite (Kerr)

Calibra Universal (Dentsply Sirona)

Adhesive Resin

Rely-X Ultimate (3M ESPE)

Multilink (Ivoclar)Calibra Ceram

(Dentsply Sirona)

Nexus NX3 (Kerr)

10.527, 8%

49.976, 35%

41.026, 29%

39.935, 28%

GIC RMGIC ARC SARC

RMGIC

GIC

ARC

SARC

The Definitive Cements Market is valued at $141M

Source: 2014 SDM Market Share Data

GIC: Glass IonomerRMGIC: Resin Modified Glass IonomerARC: Adhesive Resin CementSARC: Self-Adhesive Resin Cement

Clinicians have more than one “go to” cement for everyday use because there are varying clinical scenarios that require the use of specific material properties-isolation & adhesion

GIC RMGIC ARC SARC

RMGIC

GIC

ARC

SARC

Definitive Cements from a Clinical Strength Perspective

Source: 2014 SDM Market Share Data

GIC: Glass IonomerRMGIC: Resin Modified Glass IonomerARC: Adhesive Resin CementSARC: Self-Adhesive Resin Cement

GI/RMGI Weak

Self AdhesiveResin Cement

Not Strong

Adhesive Resin Cement

Strong

Cement Product Summary

Cements Glass Ionomer

ResinModified

Glass Ionomer

Self AdhesiveResin

Traditional Resin

Desirable Properties

Moisture tolerantFluoride release

Moisture tolerantFluoride release

Strength/Estheticswithout adhesive

step

Highest strengthGreat esthetics

Strength Moderate Moderate Good Excellent

Esthetics Moderate Moderate Good Excellent

Technique Sensitivity

Low LowModerate(requires isolation)

High(isolation &adhesion)

Ease ofUse

Very Good Excellent Moderate Difficult

Case ExamplePFZ crowns 8 & 9 cemented with Ceramir cement

Ceramir (Doxa)

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Ceramir (Doxa)

A self-sealing, acid-base reaction cementBased on NIB (NonstructurallyIntegrating Bioceramic) technologyThe cement is a new formulation class, which is a hybrid material compromised if calcium aluminate and glass-ionomer componentsFinal pH after full setting = 8.5

Ceramir (Doxa)

Ceramir (XeraCem) shows significantly higher 24-hour compressive strength than RelyX Luting Cement, and is comparable to RelyX UnicemCompressive strength of Ceramir(XeraCem) increases approximately 20% over a period of 30 days.

Source: S. Jefferies, J. Loof, CH Pameijer, D Boston et al. Physical properties of XeraCem. IADR 2008. Poster#3100.

Pre-Operative Pre-Operative

Curing Integrity Multi-Cure Final Impression using Aquasil Ultra XLV/Heavy

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Mounted Models Scanning the Models

Scanned Models Final Restorations

Cleaning the inside of the crown with Ivoclean (Ivoclar) Seating the restorations

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Removing the excess cement Final Restorations – Post-op

What we already know about Cement Selection…..

4 Major Product Categories (GI, RMGI, SARC, ARC)

There is no perfect product for every clinical scenario

The prep, crown substrate, and esthetic requirements influence product selection

Clinicians often have more than one “everyday” cement

For adhesive resin cements, system solutions work!

Dentists rely on their “clinical history” with products

Physical properties matter… so does technique and clean-up

Forces of Mastication in Action

Clinically that’s…Biting, chewing, sliding and releasing!

CompressiveVertical forces

causing it to squeeze together

Flexural Lateral forces that bend the

object

TensileResistance to

stretching and pulling

Lets Bring Flexural Strength into Action!

The cement has to help that weak ceramic!

Crown Structure Up Close

Porcelain Veneer eMax or Celtra PFM Zirconia/Layered

WEAK NOT STRONG STRONG STRONG

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Strength of Crown Materials Commonly Used

Strength Material Flexural Strength

WeakFeldspathic Porcelains

Leucite Reinforced (Empress)65-120Mpa120-160Mpa

Somewhere in the middle but definitely

not strong!

Lithium Disilicate- eMaxZirconia Reinforced Lithium Silicate (ZRS)-

Celtra300-400Mpa

StrongAlumina

Zirconia (Bruxzir)PFM

750-800+Mpa1100+Mpa

This does not take into account the influence of tooth prep and thickness…just the crown material!!!

Conventional Cement vs Bonding Decision-Prep Geometry

Cemented- not adhered to tooth structure- ZOP,GI,RMGI• Preparation with adequate cervical-occlusal height (≥4mm)

and taper between 10-20°• High strength restoration

• Bonded- bound to the tooth-SAC, ARC• Short clinical crown (≤3mm)• Over-tapered preparation greater than 20°• Low strength restoration• Not strong restoration (eMax and Celtra)

Height

Taper

What definitive cement should I use? Bond or Cement?

Good Choice

Acceptable Choice, a better choice may exist

Not Recommended

Cements‐ Product Indications

Cements/Substrate

Glass Ionomer

ResinModified GI

Self AdhesiveResin

Traditional Resin

PFM’s or All Metal Crn Yes Yes Yes Yes

All Zirconia or Zirconia Core Yes Yes Yes Yes

All Ceramic No No Yes Yes

Ceramic Inlays and Onlays No No Yes Yes

Implants Yes Yes Yes No

Cements/Substrate

Glass Ionomer

ResinModified GI

Self AdhesiveResin

Traditional Resin

PFM’s or All Metal Crn Yes Yes Yes Yes

All Zirconia or Zirconia Core Yes Yes Yes Yes

All Ceramic No No No Yes

Ceramic Inlays and Onlays No No Yes Yes

Implants Yes Yes Yes No

Ret

entiv

e P

rep

Non

-Ret

entiv

e P

rep

RecommendedCement

Clinical Tips

FeldspathicPorcelains

Adhesive ResinSelf-adhesive Resin

• Etch the porcelain with hydrofluoric acid• For bonding to porcelain, use a silanating

agent or appropriate ceramic primer

Leucite-ReinforcedCeramics (empress)

Adhesive ResinSelf-Adhesive Resin

• Etch the porcelain with hydrofluoric acid• For bonding to porcelain, use a silanating

agent or appropriate ceramic primer

Lithium DisilicateCeramics (eMax)

Zirconia reinforced lithium silicate (Celtra)

Adhesive ResinSelf-Adhesive ResinConventional Cement

• Etch to porcelain with hydrofluoric acid• For bonding to porcelain, use a silanating

agent or appropriate ceramic primer• Consider Monobond Etch & Prime• Can be conventionally cemented when

retention is adequate (eg, >4mm height)

Zirconia-Based Ceramics (Cercon, Bruxzir)

Conventional CementAdhesive ResinSelf-Adhesive Resin

• Good retention = conventional cement• Otherwise, use resin cement• Sanblast, use zirconia primer on intaglio• No silane, No hydrofluoric acid• Consider Ivoclean

Matching Cement and Crown Surface Treatments of Dental Ceramics

Ivoclean

Silane

Metal Primers

Hydrofluoric Acid

Micro-etching

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What is Hydrofluoric Acid?

HF is an inorganic acid capable of etching glass surfaces4-10% concentrations available (20-60 secs)Lithium disilicate: 20s, 5% HFNanoceramic: 40s, 5%Leucite reinforced: 60s, 5% HFFeldspathic: 120s, 9% HFCreates microretentive etching patterns on the internal surfaceWill not weaken the strength of silicate-ceramic material

JADA 2013;144(1):31-44.www.speareducation.com

What is Hydrofluoric Acid?

VERY hazardous!Extreme care must be used when handling hydrofluoric acidUse a rubber dam if using to repair porcelain in the mouthShould not be used on dentin or enamel

JADA 2013;144(1):31-44.www.speareducation.com

Instead of Hydrofluoric Acid…

Monobond Etch & Prime (Ivoclar)Etching and Silane in one stepHF-free

What is Ivoclean (Ivoclar)?

During intraoral try-in, the contamination of restoration surfaces with saliva cannot be avoidedIndicated for:Glass ceramicsZirconia/AluminaMetalIndirect composite restorations

Ivoclean (Ivoclar)

Creates optimum pre-requisites for the adhesive luting procedureEasy to Use: Simply apply Ivoclean to the bonding surface of the restoration Leave it to react for 20 secondsRinse the Ivoclean off thoroughly with water Dry the bonding surface with oil-free air

A silane coupling agent acts as an intermediary between crown and cement and improves adhesionSilane coupling agents are compounds with functional groups that bond with both organic (resins) and inorganic (glass, silica) materials

What is Silane Coupling Agent?

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What is Silane Coupling Agent?

Silanes also enhance the resin-silicate bond by promoting the wettability of the surface for the penetration of resin

Examples: Monobond-S (Ivoclar)Calibra Silane Coupling Agent (Dentsply Sirona)Rely-X Ceramic Primer (3M ESPE)Clearfil Ceramic Primer (Kuraray)Porcelain Primer (Bisco)

What are Metal Primers?

Similar concept to function of SilaneCoupling Agent

They contain bifunctional phosphate monomers that bond on one side to the metal or oxide-ceramic (zirconia, alumina) and to resin on the other side

Most contain an acidic phosphate monomer (eg, MDP)

JADA 2013;144(1):31-44.

Summary and Conclusions

Back to BasicsFocus on the Details – GiGoCreate preps that match the substrate, and are easy to impress and read by the techClosely evaluate your impressions for errorsMatch cementation procedure with the substrate for best outcomesCommunicate with the lab, they are our partners!

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THANK YOU!!!

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Documents

SUC-University of Delware-Aug2017bestdentalce.com/yahoo_site_admin/assets/docs/SUC... · A typical single-unit crown and bridge procedure requires two appointments to complete (exception