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CONTINUING EDUCATION 1 B O N D I N G Z IIR RCO NIA
How to B Bond ond Zirconia: T The he A APC PC Co Conce ncept pt Markus B. Blatz, DMD, PhD; Marcela Alvarez, DDS, MSD; Kimiyo Sawyer, RDT; and Marco Brindis, DDS
L E A R N I N G O B J E C T I VE S
Abstract: Zirconia has become become one of the most popular popul ar materials materia ls in dentistry.
Dis sc cuss the deve lopm ent of new high-translucent
New high-trenslu high-t renslucent cent zirconia ceramics have favorable favorable optical optical properties properti es and
z i rc rc o n i a c e r a m i c s
can be be applied as monolithic full-contour full-c ontour restorati rest orations ons in various clinical clinical indica tions for posterior poster ior and anterio ant eriorr teeth. However However,, having having reliable cementation
E x p l a in in t h e iim m portance o f r e s in in b o n d i n g o n t h e c l iin nical success of
protocols is fundamental fundament al for clinica clinicall success success of indirect indir ect ceramic dental restor re stora a tions, including those made from zirconia materials. Resin bonding supports ceramic restoratio resto rations ns and is necessary for onlay onlays, s, laminate veneers, and resin-
c e r a m i c r e s t o r a t iio ons D e s c r ib ib e t h e p r o p e r b o n d i n g p r o t o c o l s ffo or zirconia restorations
bonded fixed dental prostheses. The APC APC zirconia-bonding concept is is based on decades of research on how to achieve achieve high and long-term durable bond
DISCLOSURES: DISCLOSUR ES: Dr. Blatz has rece ived honor ar i a fr om N obel Bi oc ar e
strengthss to high-strength strength high-stre ngth ceramics. It includes three practical steps: (A) (A) air-
and Kur ar ay N o r i tak e D ental , and
particle abrasion, (P) zirconia primer, and (C) (C) adhesive composite resin. This This
Ms. Sawyer is a paid consultant for
research support from 3M ESPE. Kuraray Noritake.
article discusses the history histo ry and development of high-translu high-t ranslucent cent zirconia and explains the necessity for proper cementation. cementa tion. The rationale rati onale and science behind a simplified simplified zirconia-bond ing concept concept is explained and illustrated illu strated with wi th a clinical clinical case presentation.
framework.2,,3Consequently, researc hers conducting everal new materials and technologies have had a tre the zirconia framework.2 mendous impact on clin clinical ical dentistry and helped rev newer clinical studies could not find differences in the long- term perform form anc ancee betw een PFZ and p orce lain -fused-t -fus ed-t o-m o-meta etall (P FM) olutionize traditional restorative treatm ent conc olutionize concepts epts.. per Zircon.um-dioxide (Z r0 2, zirconia) ceramics have crowns.3'5Still, '5Still, widespread concerns about ven eer-porcela in chip more re techniq technique-s ue-sensi ensitive tive firing and handli handling ng of zirco zirco fundamentally changed clinical applications and the ping and the mo nia persisted, and ultim ately led to the development of CAD/ CAD/CAMCAMrange of indications for all-ceramic restorations, from single-tooth fabricated fabricate d m onolithi onolithicc full-contour zirconia restorations that did resto ratio n to full-mouth implan t-sup porte d rehabilitatio ns.1’3 not req uire app lication of a veneering porcelain. The first CAD/CAM-fabricated zirconia (more accurately Numerou Num erou s prod ucts have en enter tered ed th e marke market. t. In the m eant eantime, ime, termed yttria-stabi.ized zirconium dioxide, or yttria-stabilized millions of full-contour zirconia restorations have been inserted tetrag onal zir conia polycrystals [Y-T [Y-TZP] ZP])) coping w was as introduce d and the ir use has proven to be an effic efficient ient and cost-ef cost-effective fective alter in the late 1990s to provide a strong and more esthet ic framework native to layered indirect rest oratio ns due the CAD/C CAD/CAM AM fabrica for a porcelain-fus porcela in-fused-to-z ed-to-zirconia irconia (PFZ) restorati restoration. on. Nobel Pro Procera cera® ® tion process. Translucency of this second generation of zirconia Zirconia (Nobel Bioc Biocare, are, Nobelbiocare.com) was the first popula r materials was slightly improved compared with first-generation produc pro duct, t, followed by L Lava™ ava™ Zirco nia (3M ESPE, 3mespe.com 3mes pe.com)) in materials mate rials while retaini retaining ng similar flexural stren strength gth values. Howeve However, r, the early 20 00s. The dem and for PFZ crowns increased rapidly custom ization and individual shading had to be achi achieved eved through due thei r esthetic properties and the zirconia core material of more soaking or applying liquid liquid dye to the milled green-stage or p resin tha n 1000 MPa in high fflexural lexural strength. Early studies and clinical tered material and external staining after si sintering ntering.. experiences, however, however, indicated high incidences of cchipping hipping and fractures, especially within the veneer ing porcelain.1 porcelain.1Better Better un der To simplify the process, some manufa manufacturer cturerss have introduced pr e slightly y standing of the m aterial enabled the d evelopment of veneering por shaded zirconia blanks, some of them with multiple layers of slightl differentt shades between dentin and enamel areas to be tter simulate celains celai ns that be tter matched the physical an and d thermal prop erties of differen
S
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the appe arance of natural teeth. Restorations made with multilay-
significant signif icant infl influence uence on the clin clinical ical success of allceramic resto ra-
ered zirconia can still still be modified and customized to a ce rtain degree
tions.8''9 In general, adhes ive bonding with com posite res ins an d adtions.8
with external stains or simply poli polished shed to the d esired lust luster. er.
equate pretreatm ent of the abutmen t tooth and ceramic bondin bonding g
The latest generation of zirc zirconia onia materials has a signifi significant cantly ly higher
surface have the the ability to supp ort ceramic restorations, improve
degre e of translucency, providing greatly improved esthetics. Th e use
retention, reduce microl microleakage, eakage, and increase fracture resistance of
of multilayer hightra nsluc ent zirconia materials, in particular, pro-
the resto ration and abu tme nt tooth.10The tooth.10The clinical clinical procedu res and
vides a grea t range of esthetic possibilities possibilities,, specifically specifically for anterior
surface pretreatment steps differ, depending on the composition
teeth.6T he highe r translucenc y is achieved by slight changes of the yttria (Y (Y2 20 3) co nten t (5 mol% or more instead of the con ventional 3
and mechanical properties of the ceramic substrate.8The two m a jo r ca teg ori ories es of cer am ic m ater at er ia ls a re s ilic ilicaa bas ed (ie, fel dsp ath ic,
mol%), which is used to stabilize the tetragon al zirconia phase, caus-
leucitereinforced, lithium disilicate) and nonsilicabased high
ing a higher am ount o f cubic phase particles. Cubic zirconia offers
strength ceramics, which include alumina and zirc zirconia. onia. The quality
significantly signifi cantly grea ter light transmissio n bu t lower physi physical cal strength.
and durability of the bond between the composite resin and ceramic
High transluc ent zirconia has fl flexural exural strength values between 550
are key for clinical suc cess.81 cess.810 They typically depe nd on th e surface
MPa and 8 00 MPa MPa,, depending on the degree of tr translucency; anslucency; the
topography of the substrate, surface ene energy rgy,, and chemical interac -
highee r the translucency, the lower the flexur high flexural al strength .7Its specif specific ic
tion with the resin.8As with any adhesive interactions, contam ina-
proper pro per ties make ma ke it a viable mate material rial alte rnat rnative ive for the th e esthe esthetic tic zone. If
tion of the bonding surfaces has adverse effects on bond strengths.
bon ded de d properly , it can ca n be eve even n used for lam lamina ina te venee rs an and d onlays.
Hydrofluoricacid etching, followed followed by application of a silanecoupling agent, is recom men ded for g lassymatrix ceramics.11
Ceramic Bonding
Hydrofluoricacid etching selectively dissolves the glass matrix
Ceramic materials are brittle and can not undergo plastic deformation as m etal alloy alloyss do. Therefore, their m odulus of elasticit elasticity y and
and produces a porous, irregular surface of increased wettabilit ity. y. Application of a silanecoupling agent on th e etc hed ceram ic
be ha vi vior or un de r fun cti on al st stre ress ss is d iffe ren t from m eta etals. ls. T he cr ys ystalline struc ture all allows ows for crack propagation when the surface is
surface increases adhesion through mechanical interlocking and coupling the silica (silicon (silicon oxides) to the organic matrix o f resin
damaged o r external forces become excess excessive ive.. Therefore, the type
ma terials by me ans of siloxane bonds.11The intaglio surfaces of
of luting luting agent and technique for perman ent cem entation have a
silicaba silicabased sed ceramic restorations should not be trea ted with blunt
Preoperative extraoral view of a patient’s smile exhibiting compromised esthetic situation. Fig 2. Preoperative frontal intraoral view in maxi mum intercuspation. Fig 3. Preoperative occlusal view of maxillary arch. Fig 4. Diagnostic wax-up to determine functional and esthetic parameters.
Fig 1.
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surface-roughening methods such as air-parti air-particle cle abrasion or g rind ing as they may crea te microcracks, which function as crack initia tors an d may lead to fractures. fractures. High-strength, metal-oxide-based ceramics such as alumina and zirconia are typically considered “cem entable ” due to the ir high inher en t flexural strength, w hich exceed typical chew ing forces.8 forces.8Therefore, zirconia-based crowns and bridges bridges with adequate retention a nd ce ramic material thickness can be cemented conventionally. Resinmodified modifi ed glass-ionomer or self-adhesive self-adhesive resin cements are pre ferred and provide at least a certain level of adhesion to both teeth and ceram ic witho ut additi additional onal time-consuming and technique-se nsitive prim ing steps.912M anu fac ture rs’ instruct ions shou ld be followed closely, closely, as some recom mend air-particl air-particlee abrasion with aluminum-oxide before cem ent ap plication,13while othe rs do not. Some self-adhesive resin c e me nts can b e “tack cure d” with a curin g light for a few seconds, leav leav ing the cem ent in a d o oughy ughy stage for easy removal of excess materia l be fo re co m pl et e po ly m er iz at io n. 12I n ge ne ra l, on e sh ou ld ca re refu fu lly clean any indirect restora tion before fin final al cemen tation, for example in ethanol o r acetone in an ultrasonic cleaning unit.
The APC Zirconia-Bonding Concept W hile considered “cemen table,” some zirconia restoration s benefit from inse rtion with com posite resin-luting agent agents. s. These include zirconia restorations that are less strong, strong, are thin, lack retention, or rely on resin bonding, such as resin -bon ded fixed prosthe ses14 ses14 or bonde d lam inate veneer veneers. s. The success of resin bonding relies on the prop er materials selection selection and adequ ate treatm en t of tooth and resto ration bond ing surfaces. surfaces.8 8 T h e a b u t m e n t t o o t h i s t r eat ed w i t h a b o n d iin n g ag en t as r eco m me nded by the man ufacturer. Only dentin bonding agents speci specifi fi cally indicated indicated for ind irect restoration s should be selected, as many self-etch adhesives adhesives are limited to direct restorations du e to their increased fi film lm thickness and photopolym erization.15 The resin bo nd to high-strength ceram ics has been investiga investigated ted for more than 2 decades now. The class classic ic articl articles es by Kern and his colleagues16 colleagues1 648dem ons trated tha t for high-stre ngth ceramics, m any b o n di ng p ro to c ol s wo rk in th e sh o r t te term rm , b u t th a t st ro n g and a nd d u ra bl e lo n g -t e rm re si n bo nd s a re ac hi ev ed on ly a ft e r s ur fa ce p re tr e a t m ent with air-particle abrasion and use of an adhesive adhesive compositeresin luting agent that incorporates special adhesive phosphate
F i g 5 . P r e p a r a t io io n
c r m a x i l a r y a n t e r i o r to to o t h s e g m e n t t o c o n t r o l
v e r t iic c a l d i m e n s i o n o ' o c c l u s io i o n . F g 6 . F u l ll- c o n t o u r C A D / C A M
d e s ig n
c f m a x i lll l a r y a n t e r i o r te te e t h . F g 7 . F u l - c o n t o u r r a o r o l iitt h i c h i g h - t r a n s l u c e n t z iirr c o n i a c r o w n s f o ' re re s t o r a t iio o n s f o r m a x i la la r y a n t e r i o r tte ee th on the m a s t e r c a s tt..
monom ers, especially 10-methacryloyloxydecyl10-methacryloyloxydecyl-dihydrog dihydrogen en phos p ha te (M D P) .16 .1648 In fact , som e o f th os e ad he siv e re si n ce m e nt s we re developed to bond to metal-alloy restorations. restorations. Our first research research studi studies es on bonding to alumina and zirconia start
b u t lim ite d fe as ibi lity in d a. lv cl ini ca call p ra ct ice ic e r ou tin e. To practically practically achieve the high and long-term du rable res in bond strengths to zircon.a, we recommend a three-step approach. To
ed in the early 20 00s a nd have, have, in the meantime, comprised thou sands
simplify simpli fy this protocol protocol,, we hiv e ter med it the “APC “APC zirconia-bonding
of specimens and most surface pretre atm ent and ce men t options options
c once pt:” APC - Step A: Ait -particle ab rade the bond ing surfac e with
co mm on ly av ail ab le8i le8i9'12'13’19'21In '21In co ntr as t to ot he r st udi es, w hich use d
alum inum oxide; APC -Ste p P: Apply spec.al zirconia prim er; and
po lis he d ce ra ram m ic sa samp mp les , we inve sti gated ga ted th e ac tua l inta gli o sur fac es
AP C-Step C: Use Use dual-cure or self-cure self-cure composite resin cement.
of CAD/CA M-fabricated ceramic restorations. restorations. We found that, in ad dition to the adhesive composite resins, specifi specificc prime rs containing
APC-Ste APC -Step pA
adhesive phosp hate m onom ers, ie, ie, MDP, have the ability to bette r
After restoration cleaning, z.rconia should should be air-particle abrade d
wet the slightly rough surfaces and provide supe rior long-term bond
(APC-S tep A) with alumina o r silica-coat silica-coated ed alumina parti particles; cles; some
strengths to air-particle-abrade d h igh-strength ceramics. ceramics. Several
cal calll this procedu re sandblasting or microetching. A chairsi chairside de m icro
othe r treatm ents have been examined, including the use of various various
etche r using small perticles (£0 pm to 60 pm) at a low pressure (below
acid etchants a nd plasma coating. coating. Some have shown p romising results,
2 bar) is sufficient.9'1s“°'2 s“°'22 The overa ll effect of alum ina p re tre at m en t
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seems more impo rtant tha n actual surface roughening, roughening, especiall especially y
APC-Ste APC -Step p C
with its ability to effectively deco ntam inate the bondin g surfaces.22 surfaces.22As
Dual- or self-cure compos ites (APC - Step C) shou ld be used to ens ure
the effects effects of air-particle abrasion on th e flexural strength of zirconia
adequate polymerization/conversionbeneath the zirconia restorati restoration, on,
have been discuss ed extensivel extensively, y, most existing studies indicate th at
which reduces light transmission.8However, transmission.8However, high-translucen t zirconia
pa rti rticu cular lar ly small smal l par tic ticles les actu a ctually ally provide provi de a streng stre ng the nin g effect.23
transmits enough light that the shade of tthe he cem ent or composite-resin luting agent influences the final appearance o f such restorations. It is is,,
APC-Ste APC -Step pP
therefore, highly highly recommend ed to verify verify the anticipated ap pearance
The subsequent step includes application of a special ceramic pri p rim m e r (A PC -Step -S tep P), w hic h typ t yp ica lly co nt ain s spe cia l a dhes dh esive ive
with try-in pastes and select the mo st adequate ceme nt shade based on the individual situation and shade of the ab utm ent tooth.
ph os ph at e mo no me rs, o nto nt o th e zirc zi rcon on ia bond bo nd ing surf s urf aces ac es.2 .24 4'25Th Thee
The APC zirconia-bonding concept is not limited to teeth and
monc mer MDP, which is also also used in som e dentin bo nding agents
also applied applied in the laboratory, for example for implan t recon struc
and cem ents, has been show n to be particularly effective effective to bond
tions that include cemented zirconia components.
to metal oxides. Such primers may also increase bon ding abilities
For new high-trans lucen t zirconia products with lower flexural
of othe r cements, such as resin-mod ified glass glass ionomers, to zirco
strength, strengt h, proper bonding is even even more im portant and may be nec
nia.26However, 6However, it is highly suggested to stay w ithin reco mm ended
essary for restorations fabricated at minimum thickness. It is man
company prod uct lines for bonding agents, primers, and cements,
datory for bonded restoration s such as resin-bonde d fixed fixed dental
and to not interchange products from different manufacturers,
pr os th thes es es ,14la 4lam m in at e ve ne ers , a nd inl ay s/o nl nlay ays,2 s,27 7,28all of which wh ich
which may have similar names, bu t likely different chemical com
can be fab ricated from zirconia with excellent longevity, longevity, as long as the y are bond ed correctly.14 correctly.14
po si sitio tio ns th a t ma y no t be c om pa tib le w ith e ac h othe o the r. S om e clin cl ini i cians may be confused due to the fact tha t some special zirconia
The described APC zirconia-bonding zirconia-bonding concept is is not new but r athe r
pr im er s aalso lso co nt ai n s ila ilane nes, s, w hich hi ch ma ke t he m un iv iver er sa lly a pp li
a culmination of research studies spanning 2 decades to identify ef
cable to various materials, including silica-based ceramics. But remem ber tha t silanes have no contributing effect effect to long-term
fective, fect ive, yet clinically clinically feasible, feasible, bonding protocols. Findings fro m r e cent system atic literature reviews, which evaluated the d ata of more
bo n d st re ng th s to m et al -o x id e- ba se d ce ram ra m ic s un le ss th ey are
than 140 different zirconia-bonding studies, arrived at the same
coated w ith a silica-based ceram ic or silica-containing particles.21
conc lusion s.2 s.29 9,30It is, of course , ou r goal to co ntin ue th e s ear ch for
Fig 8. Maxillary occlusal view of cemented anterior full-contour high-translucent zirconia crowns and refined conservative preparations of posterior teeth for onlays and crowns. Fig 9. Occ Occlusal lusal view of posterio posteriorr mon monolithic olithic high-translucent zirconia restorations on the model. Fig 10. Lingual view of maxilla y right posterior high-translucent zirconia restorations on the model. Fig 11. Lingual view of maxillary left posterior high-translucent zirconia restorations on the model. Fig 12. Posterior monolithic high-translucent zirconia onlay and crown restorations.
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resin cement (Panavia SA, Kuraray Noritake Dental). Figure 8 demonstrates the cemented anterior crowns and refined conser vative vati ve preparations of posterior teeth, which were performed with minimal tooth-structure removal. High-translucent monolithic Case Ca se Presentation Presenta tion UT, A 40-year-old patient presented w ith the chief complain complaint: t: “My zirconia onlays and crowns were fabricated (Katana Z irconia UT, tee th are cracking, and I would like to have my original bite.” Den Kuraray Noritake Dental) (Figure 9 to Figure 12). The posterior restorations were adhesively bonded following the APC zirconiatal findings findings includec Class I occlusion with slight misalignment
possibly even m ore effective bonding metho ds to broa b roaden den clinical indications and increase the longevity of zirconia-based restorations. restorations .
bet wee n tee th Nos. 8 and 9. betwee 9. Generaliz Gener alized ed severe occlusal occlusa l wear and slight Class I mobility of tee th Nos. 23 to 26 were noted. Caries le sions were foun d on tee th Nos. 2,4 , 6, 8, 8, 9 9,, and 14 and abfrac tion lesions on teeth Nos. 4, 5,10,11,13, 20, and 21. Figure 1 through Figure 3 depict the preoperative situation. Full-mouth rehab ilita tion was suggested. suggested. The goals goals for the restorative trea tme nt were managem ent of erosive etiol etiology ogy,, c onservation of tooth structure, and long -term protec tion of the restorations. A diagnostic diagnostic wax-up wax-up was instrumental in determining functional functional and esthetic treatmen t goals and establishing new anteri or guidance (Figure 4). A compre hensive, step-by-step treat me nt approach was applied, which, after per iod iodont ont al pr pretr etr ea eatm tm en ent, t, caries control, cont rol, and provision prov isionaliza alization, tion, included definiti definitive ve prepara tion (Figure 5) and restoration of the the maxillary anterior teeth to establish anterior occlusal guidance. CAD/CAM -fabricated full-contour monolithic high-translucent zirconia crowns (Kata (Katana™ na™ UTML U ltra Tran slucent Multi-Lay ered, Kuraray Noritake Dental, kuraraynoritake.com) were fab ricated (Figure 6 and Figure 7) and cemented with self-adhesive
bon ding conce pt. APC-S tep A involved air-p article bonding arti cle ab rasi rasion on with 50-gm aluminum oxide at 1.5 bar with a chairside microetcher (Figure 13), followed by application (APC-Step P, Figure 14) of a special speci al ceramic prim er (Clearhl™ (Clearhl™ Ceramic Primer, Kuraray N ori take) with adhesive adhesive phosophate monomers (MDP). (MDP). Relative Relative mois ture and contamination control was achieve achieved d with cotton rolls and retractio n cords. Rubber dam placem ent, which is always always preferred, was difficul difficultt in this situation. Th e enamel surfaces o f the abut men t tee th were selectively etched (Figure 15) 15) with 35% phosphoric acid (K-Etchant Gel, Kuraray Noritake Dental) and the dentin conditioned (Figure 16) 16) with a self-etch self-etch dentin prim er (Panavia V5 Tooth Primer, Kuraray Noritake Dental). A dual-cu re adhesive resin (Panavia V5 V5 Paste Universal, Kuraray Noritake Denta l) was dispensed directly into the restor ations with an automix syringe. syringe. The restorations were inserted, and excess cement was careful carefully ly removed (Figure 17 and Figure 18) before light polymeriza tion (Figure 19). Postoperative views depict the treatment outcome (Figure 20 to Figur e 22).
Fig 13. The APC-step A: air-particle abrasion with 50-pm aluminum oxide at 1.5 bar with chairside microetcher. Fig 14. The APC-step P: application of specia speciall ceramic primer with adhesive phosophate monomers. Fig 15. Selective enamel etching of abutment teeth with phosphoric acid for 20 seconds. Fig 16. App lica tion of s elf-etch dentin primer. Fig 17. The APC-step C: application of dual-cure composite resin. Insertion of restorations and cleaning of excess composite material with a sable brush.
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Conclusions Reliable cementation protocols and materials are fundamental for
Queries to the authors regarding this course may be submitted to
[email protected]..
[email protected]
clinicall success of indirect ceramic de ntal restora tions, including those clinica made from zirconia materials. New high-transluc ent zirconia ceram
REFERENCES
ics have favorabl favorablee optical properties and can b e applied as m onolithic full-contour restora tions in various clinical indications indications for posterior and an terior teeth. Resin bonding supports ceramic restorations restorations and is necessary for onlays, onlays, laminate veneers, and resin-bonded fixed fixed dental pros theses. prosthes es. The APC zircon zirconia-bo ia-bo ndin g con concep cep t is bas ed on deca decades des of research on ho wto achieve hi high gh and long-ter long-term m durable bond strengths to zirconia. It includes three practical steps: (A (A)) air-particle abrasion, (P) zirconia primer, and (C) adhesive composite resin.
AB OUT THE AUTHORS
Markus B. B. Blatz, D DMD, MD, PhD Professo Prof essorr o f Re sto rat ive Den tist ry ; Chair, Chair, Depar tment of Preventive and Restorative Sciences, Scien ces, School of of Dent Dent al M Medicine, edicine, University of Pennsylvania, Philadelphia, Pennsylvania
Marcela Alvarez, DD DDS, S, MSD Privat e Practice, Practice, San Antonio, Texas
Kimiyo Sawyer, Sawyer, RD RDT T President, Cusp Dental Laboratory, Laboratory, Malden, Massach usetts
1. Komine F, Blatz MB, Matsumura H. Current status of zirconia-based fixed restorations. J Oral Sci. 2010;52(4); 2010;52(4);531-539. 531-539. 2. Blatz MB, Bergler, M, Ozer F, et at Bond strength of different ve neering ceramics to zirconia and their susceptibility to thermocycling. Am J Dent. 2010;23(4):213-216. 3. Saito A, Komine F, Blatz MB, Matsumura H. A comparison of bond strength of layered veneering porcelains to zirconia and metal. J Pros- thet Dent. Dent. 2010;104(4):247-257. 4. Ozer F, Mante FK, Chiche G, et at A retrospective survey on long term survival of posterior zirconia and porcelain-fused-to-metal crowns in private practice. Quintessence Int. 2014;45(l):31-38. 5. Takeichi T, Katsoulis J, Blatz MB. Clinical outcome of single porcelain-fused-to-zirconium dioxide crowns: crowns: a systematic rev review iew.. J Prosthet Dent 2013;110(6):455-61. 6. Bergler M, Blatz MB, Mante FK. Translucency of full-contour zirconia ceramics. J Den t Res. Res. 2015;94(Spec issue A):3534 (Abstr). 7. Conejo J, Kobayashi K, Mante F, Blatz MB. Flexural strength of new high-translucent zirconia and lithium disilicate ceramics with two spec Res. s. 2016;95(Spec issue B):1162 (Abstr). imen dimensions. J Dent Re 8. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature.
J Pro sthet Dent. Dent. 2003;89(3):268-274.
Marco Brindis, D DDS DS
9. Blatz MB, Oppes S, Chiche G, et al. Influence of cementation tech
As sis tan t Pro fesso r o f Clinical Prosthodontics Prosthodontics and Interim Chair, Chair, Departmen t of
nique on fracture strength and leakag leakage e of alumina all-ceramic crowns after cyclic loading loading.. Quintessence Int. 2008;39(1):23-32.
Prosthodontic Prostho dontics, s, Louisiana S tate University School of Denti of Denti stry, N ew Orlea ns, Lou isia na
Fig 18. Careful interproximal removal of excess composite material. Fig 19. Light polymerization of composite resin for 60 seconds from each side. Fig 20. Postoperative occlusal view of maxillary arch with full-contour monolithic high-translucent zirconia restorations on all teeth. Fig 21. Postoperative frontal intraoral view in maximum intercuspation with full-contour high-translucent zirconia restorations. Fig 22. Postoperative extraoral view of patient’s smile.
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10. Burke FJ, Fleming GJ, Nathanson D, Marquis PM. Are adhesive technologies needed to s upport ceram ceramics? ics? An assess assessment ment of the cur rent evidence. J Adhes Dent. Dent. 2002;4(1):7-22. 11. Blatz MB, Sadan A, Maltezos C, et al. In vitro durability of the resin bond to feldspathic ceramics. Am ceramics. Am J Dent. Dent. 2004;17(3):169-172. 2004;17(3):169-172. 12. Blatz MB, Bergler M. Clinical application of a new self-adhesive res in cement for zirconium-oxide ceramic crowns. Compend Contin Educ Educ Dent. 2012;33(10):776-781. Dent. 2012;33(10):776-781. 13. Blatz MB, MB, Phark JH Ozer F, et al. al. In vit vitro ro compar co mparativ ative e bond s stren trength gth of contemporary self- adhesive resin cements to zirconium oxide ceramic with and withou t air-particle abra abrasion sion.. Clin Oral Investig. Investig. 2010;14(2):187-192. 14. Maggio M, Bergle- M, Kerrigan D, Blatz MB. Treatment of max illary lateral incisor agenesis with zirconia-based all-ceramic res in bonded fixed partial dentures: a case report, Am report, Am er J Esthet Dent. Dent. 2012;2(4):226-237. 15. Ozer F, Blatz MB. Self-etch and etch-and-rinse adhesive systems in clinical dentistry. Compend Contin Educ Dent. Dent. 2013;24(l):12-20. 16. Kern M, Thompson VP. Bonding to glass infiltrated alumina ce ramic: rami c: adhesiv adhesive e method s and th eir durability. J Prosthet Dent. Dent. 1995;73(3):240-249, 17. Kern M, Wegner SM. Bonding to zirconia ceramic: adhesion meth ods and their durabil ty. Dent Mater. Mater. 1998;14(1):64-71. 1998;14(1):64-71. 18. Wegner SM, Kern M. Long-term resin bond strength to zirconia ce Dent. 2000;2(2):139-147. ramic. J Adhes Dent. 19. Blatz MB, Sadan A , Arch GH Jr, Jr, Lang BR BR.. In vit ro evaluatio n o f lo ng term bonding of Procera AllCeram alumina restorations with a modi fied resin luting agert. J Prosthet Dent. Dent. 2003;89(4):381-387. 20. Blatz MB, Sadan A, Martin J, Lang B. In vitro evaluation of shear bond strengths of resin to densely-sintered high-purity zirconium-ox ide ceramic after long-term storage and thermal cycling. J Prosthet
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CHICAGO2017 ch che e AMERICAN PROSTHODONTIC SOCIETY
Dent. 2004;91(4):356-362. Dent. 2004;91(4):356-362. 21. Blatz MB, Chiche G, Holst S, Sadan A. Influence of surface treat
ment and simulated aging on bond strengths of luting agents to zirco nia. Quintessence int. int. 2007;38(9) 2007;38(9):745-753. :745-753. 22 . Quaas AC, Yang B, Kern M. Panavia F 2.0 bonding to contaminat ed zirconia ceramic after different cleaning procedures. Dent Mater. Mater. 2007;23(4):506-512. 23. Song JY, Park SW, Lee K, et al. Fracture strength and microstruc ture of Y-TZ Y-TZP P zirconia after differen t surface treatments. J Prosthet Prosthet Dent. 2013;110(4):274-280. Dent. 2013;110(4):274-280. 24 . Koizumi FI, Nakayama D, Komine F, et al. Bonding of resin-based luting cements to zirconia with and without the use of ceramic prim ing agents. J Adhes Dent. Dent. 2012;14(4):385-392. 25. Nakayama D, Koizumi H, Komine F, et al. Adhesive bonding of zir conia with single-liquid acidic primers and a tri-n-butylborane initiated acrylic resin. J Adhes Dent. Dent. 2010;12(4):305-310. 26 . Alnassar T, Ozer F, Chiche G, Blatz MB. Effect of different ce ramic primers on shear bond strength of resin-modified glass ionomer cement to zirconia. zirconia. J Adhes Sci Technol. Technol. 2016; DOI: 10.1080/01694243.2016.1184404. 27. Blatz MB. Long-term clinical success of all-ceramic posterior resto rations. Quintessence Int. Int. 2002;33(6):415-426. 28. Mante FK, Ozer F, Walter R, et al. The current state of adhesive dentistry: a guide for clinical practice. Compend Contin Educ Dent. Dent. 2013;34:Spec 9:2-8. 29. Ozcan M, Bernasconi M. Adhesion to zirconia used for dental restora tions: a systematic review and meta-analysis. J Adhes Dent. Dent. 2015;17(1):7-26. 30. Inokoshi M. De Munck J, Minakuchi S, Van Meerbeek B. Meta es.. analysis of bonding effectiveness to zirconia ceramics. J Dent Res 2014;93(4):329-334.
8 9 THA N NUA L M E E T I NG OF THE AMERICAN PROSTHODONTIC SOCIETY FEBRUARY FEBRUAR Y 23-2 4, 2017 2017 I SWISSOTEL
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TECHNOLOGY & ART ART
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CONTINUING EDUCATION 1 QUIZ
How to Bond Zirconia: The APC Concept Con cept Markus B. Blatz, DMD, PhD; Marcela Alvarez, DDS, MSD; Kimiyo Sawyer, RDT; and Marco Brindis, DDS
This article provides 2 h ours of CE credit from AEGIS AEGIS Publications, LLC. LLC. Record your answers on the enclosed Answer Form or subm it them on a separa te she et of paper. Yo You u may als also o phon e your answers in to 877-423-4471 877-423-4471 or fax them to 215-504215-504-1502 1502 or log on to co mpendiumce.com/go/1637. Be sure to include your name, address, telephone number, and last 4 digits of your Social Security number.
Please complete Answer Form on page 628, including your name and payment information. YOU CAN ALSO TAKE THIS COURSE ONLINE AT COMPENDIUMCE.COM/GO/1637.
1.
The increased translucency of recent high-transl ucent zirconia materials is due to:
A. B. C. D.
2.
3.
A. B. C. D.
100 MPa MPa and 24 0 MPa. 240 24 0 MP MPa a and 55 550 0M MPa Pa.. 550 55 0 M MPa Pa and 80 0 MP MPa. a. 1000 10 00 MPa and 1500 MPa.
7.
the higher the translucency, the higher the flexural strength. the higher the translucency, the lower the flexural strength. the lower lowe r the translucency, the lower the flexural strength. the degree of translucency is not correlate correlated d with flexural strength.
8.
hydr oflu ofluoricoric- acid etching and silane appl application. ication. grinding with diamond bu r a and nd silane silane application. air-particle abrasion withou t any other surface treatment. sila silane ne application wi thout any other surface surface treatment. treatment.
The preferred surface treatm ent when bondin g to zirconia iis s:
A. hydr oflu ofluoricoric- acid etchin etching g and silane applicat ion. B. grin grinding ding with wi th diamond bur and silane applica application. tion. C. air-p artic le abrasion wit h alumina and zirconia primer application. D. sila silane ne application w ithou t any other surface treatment.
undergo unde rgo plastic defo rmat ion as metal alloys do. behave like metals under function al stre stress. ss. have the same modulus of elasti elasticity city as metals. canno t undergo plastic defo deforma rmation tion as metal alloys do.
9.
increases increases the their ir f racture resist resistance. ance. reduces microleaka microleakage ge improves retention. All of the above above
Special zirco nia primers:
A. typical typi cally ly contain adhesive ph phosphate osphate monomers, such as MDP, which bond to metal oxides. B. are not no t necessary. C. always come in differe different nt shades to match the adjacen t tooth color. D. must be appli applied ed before air-particle air-pa rticle abrasion.
Adhesive bondi ng of ceramic restorations:
A. B. C. D.
Air-part icle abrasion of zirconia bondi ng surface surfaces: s:
A. should never be done. B. is not no t necessary. C. must be done with large alumina particles (at least 110 pm) at high pressure of above 4 bar. D. can suffi sufficien cien tly be done with small alumina particles particle s (50 pm to 60 pm) at low pressure below 2 bar.
CeCe-amic amic materials are brit tle and and::
A. B. C. D. 5.
The preferred surface treatm ent when bondi ng to silica-based ceramics is:
As a general rule for zirconi a:
A. B. C. D.
4.
a higher amou amount nt of c ubic-pha ubic-phase se pa particles. rticles. a lower amount of cubic-phase particles. new staining techniques. excessive sinte sintering ring..
High-transluc ent zirconia has has flexural strength value values s between:
A. B. C. D.
6.
10. 10.
Composit e resins resins for z zircon ircon ia bonding:
A. B. C. D.
Course is valid from 10/1/2016 to 10/31/2019. 10/31/2019. Participan ts must atta in a score of 70% on each quiz to receive credit. Par ticipa nts receivin g a failing grade on any exam will be notified and permitted to take one re-examination. re-examination. Participants will receivee ar. annual report d ocumenting thei r accumulated receiv credits, and are urged to contact their own state registry boar ds for spe cial CE re quir eme nts.
AnA
should be lilight-c ght-c ure materials. should be dual- or self-cure materials. are not available in diffe ren rentt shades shades.. None of the above
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COMPENDIUM
October 2016
Volume 37, 37, Num ber 9
C o s H
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