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Dental biomaterials science: building long lasting

aesthetic restorations
Associate Prof. Paulo Francisco Cesar
University of So Paulo
School of Dentistry
Department of Biomaterials and Oral Biology

Collaborators:
Prof. Lucas Hian da Silva
Prof. Susana Salazar-Marocho

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paulofc@usp.br

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Universidade de So Paulo
Faculdade de Odontologia
Departamento de Biomateriais e Biologia Oral

Outline:
1. Ceramics
2. Surface treatments
3. Cements

1. Ceramics
1.1. What are the options?

1.2. Material of choice


1.2.1. Clinical failures
1.3. The future

1. Ceramics
1.1. What are the options?

1. Ceramics
1.1. What are the options?

Brands

Porcelains

VM7, VM9, VM13 (Vita), d.Sign (Ivoclar), Super-Porcelain


EX-3/Cerabien (Noritake), Duceram Kiss (Degudent).

Glass-ceramics

E.Max Sistem: leucite or lithium disilicate (Ivoclar).

Glass-infiltrated composites

In-Ceram Sistem from Vita (Al, Zr, Spinell).

Polycrystalline ceramics

In-Ceram2000 (Vita), Lava (3M), Cercon (DeguDent),


Everest (Kavo), Zeno (Wiedland).

1. Ceramics
1.1. What are the options?

Porcelains
Glass-ceramics
Glass-infiltrated composites
Polycrystalline ceramics

Porcelains

Borba, 2010

Porcelains
1

Alberto Calazans

Glass-ceramics (leucite or lithium disilicate)

Gonzaga, 2007

Glass-infiltrated composite

Polycrystalline

Alumina

Y-TZP

Borba, 2010

1. Ceramic
a) Leque de opes
1.2. Material of choice

b) O material de escolha

c) Novas perspectivas

1. Ceramics
1.2. Material of choice
Veneers

Inlays /Onlays
Crowns

Fixed partial dentures


Abutments
Large infra-structures for implants

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Veneers

Porcelains or Glass-ceramics

Dr. Alexandre Cesar

Porcelains

Inlay/Onlay
1

Porcelains or Glass-ceramics
2

Glass-ceramics
1

2
3

Crowns
High translucency:

coping+veneering ceramic

Glass-ceramics (coping+veneering ceramic or monolithic)

Dr. Walter Miranda

Glass-ceramics (monolithic)

Dr. Jamil Shibli

Glass-ceramic (monolithic)

Dr. Jamil Shibli

Glass-ceramic (monolithic)

Dr. Jamil Shibli

Crowns

Low translucency
1

Dr. Alexandre Cesar

Y-TZP

Fixed partial dentures

Y-TZP

Cercon/Dentstply

Abutments

Y-TZP

Dr. Susanne Scherrer (Univ of Geneva)

Dr. Jamil Shibli

Large infra-structures over implants

Lohbauer et al., 2010

Lohbauer et al., 2010

Failed from a stress concentrating zone at the


tip of the zirconia framework (origin);

Crack moved in a downward direction;

A secondary edge chip on the palatal exposed


zirconia framework was incidental and not
related to the final failure.

Lohbauer et al., 2010

Large infra-structures over implants

Dr. Susanne Scherrer (Univ. of Geneva)

Large infra-structures over implants


1

Metal

Dr. Alexandre Cesar

1.2.1. Clinical failures


Secondary caries/marginal discoloration/
wear of cement line/ minor edge chippings
Dr. Susanne Scherrer

Debonding

Fractures
Veneers/Inlay/Onlay/Crowns

Fixed partial dentures (FPDs)

Secondary caries/marginal discoloration/wear of cement line/minor edge chippings

Secondary caries/marginal discoloration/wear of cement line/ minor edge chippings

Due to the posterior location of the restorations, these timedependent degradation processes were not of concern clinically
and were only observed by the examiners.

Debonding

Evaluation of tensile retention of Y-TZP crowns after long-term aging: effect of the core
substrate and crown surface conditioning.
Amaral R, Rippe M, Oliveira BG, Cesar PF, Bottino MA, Valandro LF.
Oper Dent. 2014 Nov-Dec;39(6):619-26.

Evaluation of Tensile Retention of Y-TZP Crowns Cemented on Resin Composite Cores: Effect
of the Cement and Y-TZP Surface Conditioning.

Rippe M, Amaral R, Oliveira F, Cesar PF, Scotti R, Valandro L, Bottino M.


Oper Dent. 2015 Jan-Feb;40(1):E1-E10.

After 42 months one


occurred in each group;

debonding

No effect of resin cement: Panavia 21


versus Multilink.

1.2.1. Clinical Failures


Fractures
Inlay/Onlay/Crowns

Zhang et al., 2014

Zhang et al., 2014

Inlay/Onlay/Crown
Defects on the cementation surface

Dicor crown in a premolar

Thompson et al., 1994

Zhang et al., 2014

Inlay/Onlay/Crowns

Marginal defects

Procera crowns (alumina coping + veneering porcelain)

Quinn et al., 2005

Fractographic Analysis of 13 incisors, 3


premolars and 11 molars;

All fractures initiated in the cervical margin of


the crowns and usually from the proximal
area close to the most coronally placed

curvature of the margin.

Oilo et al., 2014

Cesar, 2012

Cesar, 2012

Zhang et al., 2014

Inlay/Onlay/Crown

Kim et al., 1999

Cone cracks (NO attrition)

Post-indentation half-surface (top) and section view


(bottom), monolith porcelain specimen (Vita Mark II,
Vita Zahnfabrik) loaded axially in cyclic fatigue. Note
deep-penetrating cone cracks from inner contact zone.

Zhang et al., 2009

Inlay/Onlay/Crown

Cone cracks (NO attrition)

Fardim, 2013

Inlay/Onlay/Crown

Cone crakcs (NO attrition)

Fardim, 2013

Inlay/Onlay/Crown

Cone crakcs (NO attrition)

Fardim, 2013

Inlay/Onlay/Crown

Cone cracks (NO attrition)

Fardim, 2013

Zhang et al., 2014

Inlay/Onlay/Crowns

Partial cone cracks (WITH attrition)

Kim et al., 2008

Kim et al., 2010

Optical micrographs showing


(a) surface (top) and side view
(bottom) sliding wear track on
Y-TZP surface caused by WC
sphere of radius r=1.5 mm
under normal load of 1000 N.

Inlay/Onlay/Crown

Dr. Jamil Shibli

Partial cone cracks (WITH attrition)

In vivo

In vitro

Zhang et al., 2014

Inlay/Onlay/Crown
Chipping

Fracture of the porcelain layer (AllCeram) over


Procera Alumina after 4 years.

Scherrer et al., 2007

Scherrer et al., 2007

Inlay/Onlay/Crown
Chipping

Porcelain fused to metal fractured after 2 months.

Courtesy Susanne Scherrer

compression curl

Courtesy Susanne Scherrer

Compression
curl

2 blunt contacts

Courtesy Susanne Scherrer

Courtesy Susanne Scherrer

Belli et al., 2014

In the chipping area a small bubble within the


veneering material (size 1 x 0.2 mm) is visible;
The chipping occurred 7 months after insertion

2009 Jun;5(5):1668-77

Koenig et al., 2007

Chipping/incisal edge

Fracture

Chipping/cervical area

Multiple cracks

Quintessence Int 2014;45:369376

InCeram Alumina + Veneering porcelain

Critical crack initiated at the incisal contact area and


propagated gingivally;

The estimated stresses were lower than the measured


strength of the veneer materials;

Contact damage, fatigue, and processing flaws within the


veneer lead to chipping of veneering porcelain in anterior
lithium disilicate and glass-infiltrated alumina crowns.

Qian et al., 2014

Fractography: Y-TZP coping veneered with glass-ceramic.


Authors: Rodrigo Souza, Susana Salalar-Marocho and Paulo Cesar
Age: 22 years;

Gender: female;
No parafunctional habits;
Metal post;

Luting cement: U100 (3M);


Lifetime: 1 year;
Slow cooling;

Y-TZP Coping: Lava (3M);


Veneering ceram: Emax Ceram;

Cohesive fracture veneering ceramic

Adhesive fracture (delamination)


exposing the Y-TZP coping

(Mesial)

Arrest lines

Origin is here (occlusal).

Arrest lines indicate direction of crack propagation.

Roughness of occlusal surface (buccal cusp).

Area without loss of glaze


layer (but a bit porous)

Multiple
damage.

areas

of

Wear of the glaze layer.

occlusal

Multiple hackle lines.

Origin

Conclusion
Origin on occlusal surface;
Relationship with cumulative damage on glaze layer;
Delamination was observed;
Problem with coping design.

Courtesy Rodrigo Souza

Courtesy Rodrigo Souza

Courtesy Rodrigo Souza

Fracture rates (%) of the venering porcelain applied over Y-TZP in clinical trials
Continued...
Study
Larsson
Rinke
Zembic
Ortorp
Vigolo
Lops
Burke
Sailer
Schmitter
Schmitt
Molin
Sagirkaya
Pelaez
Salido

Year
2013
2013
2012
2012
2012
2013
2013
2007
2012
2012
2008
2012
2012
2012

Koenig et al., 2007

%Fracture
88.9
28.8
0
3
7.7
10.8
24.2
15
26.7
28
0
0.9
10
29.1

Beuer
Tinschert
Rinke
Sailer
Edelhoff
Beuer
Schmitt
Papaspyridakos
Raigrodski
Pospiech
Esquivel-Upshaw
Tsumita
Cehreli
Ohlmann
Bornemann
Ohlmann
Larsson

2010
2008
2013
2009
2008
2009
2010
2012
2006
2003
2013
2010
2009
2012
2003
2008
2006

7.4
6
5.8
33.4
9.5
0
5.9
31.3
25
2.6
16.7
14.3
0
20
3.3
13
54

grade 1 = small chip that does not demand any action, except polishing.

grade 2 = moderate chip that can be repaired.


grade 3 = large chip that leads to replacement of the prosthesis.

Heintze & Rousson 2010

Technologies to overcome the problem of chipping

Pressing the veneering ceramic over Y-TZP

CAD-on system

Rapid layer technique

Pressing the veneering ceramic over Y-TZP

http://sayakaattitude.blogspot.com/2011/07/emax-zirpress-2.html

Arajo et al., 2015

Arajo et al., 2015

Arajo et al., 2015

Sintered

Flexural strength
(MPa)

51.3 4.9c

Sintered
+
Fibers

65.2 4.4b

Hot-pressed

67.1 7.9b

Hot-pressed
+
Fibers

76.5 11.0a

Arajo et al., 2015

Sintered

Sintered + Fibers

Hot-Pressed

Hot-Pressed + Fibers

Arajo et al., 2015

POROSITY (%)

Sintered: 4.0 1.1b

Hot-Pressed : 0.3 0.2c

Sintered + Fibers: 10.4 4.5a

Hot-Pressed + Fibers: 2.6 2.4b,c

Arajo et al., 2015

CAD-on system

Source: www.ivoclar.com

Rapid layer techique

http://www.vita-zahnfabrik.com/

http://www.vita-zahnfabrik.com/

http://www.vita-zahnfabrik.com/

1.2.1. Clinical failures


Fractures
FPDs

Zhang et al., 2014

Fractures
FPDs

Zhang et al., 2014

Borba et al., 2015, accepted in Dent Mater

Fractures
FPDs

CC
HL

Borba et al., 2015, accepted in Dent Mater

FRACTURE ORIGIN AT THE INTERFACE


(ALUMINA + VM7)

Borba, 2010

Dent Mater. 2008 Aug;24(8):1077-82

Primary fractures in clinically failed Y-TZP-based


FPDs initiated from the veneer surfaces.
Interfacial delamination in glass veneer/zirconia
core bilayer dental ceramic structures controlled

the secondary fracture initiation sites and failure


stresses in Y-TZP-based fixed partial dentures.

Taskonak et al., 2008

Proper treatment planning is needed to ensure an adequate connector


height of 4 mm or more on allceramic prostheses made with a lithia
disilicatebased core ceramic.

1. Ceramics
1.3. The future

1. Ceramics
1.3. The future

Monolithic zirconia
Lithium silicate with zirconia particles

Interpenetrating ceramic-resin composite network

Monolithic zirconia (Lava Plus, 3M)

Edmara Bergamo, Master Thesis, 2015


Advisor: Altair Cury (Unicamp/Brazil)

Edmara Bergamo, Master Thesis, 2015


Advisor: Altair Cury (Unicamp/Brazil)

CONTROL
AGED

Edmara Bergamo, Master Thesis, 2015


Advisor: Altair Cury (Unicamp/Brazil)

Edmara Bergamo, Master Thesis, 2015


Advisor: Altair Cury (Unicamp/Brazil)

Lithium silicate with zirconia particles (Suprinity, Vita)

Nathlia Carvalho, Master Thesis, 2014


Advisor: Renata Melo (UNESP/Brazil)

Source: Vita

Interpenetrating ceramic-resin composite network (Enamic, Vita)

Nathlia Carvalho, Master Thesis, 2014


Advisor: Renata Melo (UNESP/Brazil)
Source: Vita

Lithium silicate (Suprinity)

Monolithic Y-TZP

Denry & Kelly, 2014

2. Surface treatments

2.1. What are the options?

Acid etching
Silanes

Sandblasting with alumina particles


Sandblasting with alumina particles covered with silica (Tribo-chemical).

Ceramic primers

Acid etching (Hidrofluoric acid

HF)

Micromechanical bonding between ceramic and adhesive/resin cement

Cesar, 2002

Silane
Bi-functional molecule (bonds to silica and resin composites)
It is used in association with HF or Tribo-chemical treatment
Brands: Monobond-s (Ivoclar Vivadent), Prosil (FGM), Silane (Ultradent).

Silane
Bond strength between resin cement and porcelain
Bond strength (MPa)

25

20

15

10

Control
Sem
TC

Aged
Com
TC

HFHF
com
withsilano
silane

Control
Sem
TC

AgedTC
Com

sem silano
HFHF
without
silane

Brentel et al., 2007

Sandblasting with alumina particles

Parameters:
Particle size: 50 to 150 m
Pressure: 2.8 bar
Time: 10 s
Distance :10 mm

Queiroz et al., 2012

Sandblasting with alumina particles

Bond strength between resin cement and Y-TZP

Amaral et al., 2008

Sandblasting with alumina particles


Creation of critical flaws versus compressive layer (Y-TZP)

Compression layer

3M ESPE
Zhang et al., 2006

Sandblasting with alumina particles covered with silica

Impact on the surface at high velocities.

Formation of silica layer.


Chemical bonds between silica and silane.

3M ESPE

Sandblasting with alumina particles covered with silica


Brands:
Rocatec Plus (particles of 110 m)
Cojet or Rocatec Soft (particles of 30 m)

Sandblasting with alumina particles covered with silica

Bond strength (MPa)

Bond strength between resin cement and Y-TZP

30
25
20
15
10
5
0
Control
controle

Aged
envelhecido

Sandblasting
Jateamento

Control
controle

Aged
envelhecido

Alumina
+ silica
Silicatizao

Kern et al., 1998

Primers for ceramic materials


Phosphate-based monomers (MDP, VBATDT)
Chemical bonds between metallic oxides (e.g., ZrO2) and resin cement.
Brands:

Metal/Zirconia Primer (Ivoclar Vivadent), Porcelain Primer (Bisco),


Clearfil Ceramic Primer (Kuraray).

Primers for ceramic materials


Bond strength between resin cement and Y-TZP after thermocycling
Koizumi et al., 2012
Bond strength (MPa)

6
5

4
3
2
1
0

Control
Sem
TC

Aged
Com
TC

MZ Primer + Multilink

Primers for ceramic materials


Best results were seen when primers are associated to other surface treatments

Bond strength (MPa)

Y-TZP-after Cojet

48

51
35

35

Silane
SILANO

Silane
+ MDP
SILANO+MDP

CONTROLE
Control

Silane
SILANO

Silane
+ MDP
SILANO+MDP

ENVELHECIDO
Aged

Tanaka et al., 2008

Amaral et al., 2014

2. Surface treatments
2.2. Treatment of choice

Porcelains and glass-ceramics


Glass-infiltrated composites and polycrystalline

HF + Silane

Porcelains and Glass-ceramics


HF concentration: 8 to 10%
Ceramic group

Time

Porcelains

1 to 2 min

Glass-ceramics
(leucite)

1 min

Glass-ceramics
(lithium disilicate)

20 to 30 s

Glass-infiltrated composites and


polycrystalline

Cojet + silane/primers

Courtesy: FGM

2. Surface treaments
2.3. The future

Glaze layer on the internal surface of Y-TZP crowns

Internal glaze layer


Application of glaze layer on the internal surface of Y-TZP crowns.

Makes the surface susceptible to HF

Vanderlei et al., 2013

glaze spray

glaze powder/liquid

HF etching

Internal glaze layer

Vanderlei et al., 2013


Glaze + HF

3. Cements
3.1. What are the options?
Zinc phosphate
Conventional glass-ionomer cements (GIC)

Resin modified GICs


Resin cements:

Conventional
Conventional + self-etching primer
Self-adhesives

Resin modified GICs


Fluoride release and control of setting time

Brands: RelyX Luting 2 ou Plus Automix (3M ESPE)

Resin Cements
Conventional

acid +

primer + bond

cement

Conventional +
Self etching primer

Self-adhesive

Self-etching primer

cement

cement

Resin cements
Conventional

Conventional +
Self etching primer

Self-adhesive

Photo-activated
Dual

Dual

Chemically

Chemically

activated

activated

Dual

Resin Cements
Conventional

acid +

primer + bond

cement

Conventional +
Self etching primer

Self-adhesive

Self-etching primer

cement

cement

Conventional resin cement


Photo-cured
Less quantity of amines (chemical activators) = better color stability
Brands: RelyX Veneer (3M ESPE) e Variolink Veneer (Ivoclar)

Conventional resin cement


Dual
Stable bond strength to dental tissues: interaction with the best adhesive systems
Brands: RelyX ARC (3M ESPE), Variolink II (Ivoclar) and EnForce (Dentsply)

Anusavice, 2009

Resin Cements
Conventional

acid +

primer + bond

cement

Conventional +
Self etching primer

Self-adhesive

Self-etching primer

cement

cement

Conventional resin cement+ Self-etching primer


Dual
Brands: Panavia F 2.0 (Kuraray) e Multilink (Ivoclar)

MDP:
10-methacryloxydecyl dihydrogen phosphate (MDP)

MDP
Y-TZP
Resin
composite

Dentin/
Enamel

Resin Cements
Conventional

acid +

primer + bond

cement

Conventional +
Self etching primer

Self-adhesive

Self-etching primer

cement

cement

Self-adhesive cements
Dual
One step, less technique sensitive.
Brands: U200 (3M ESPE), SmartCem 2 (Dentsply) and Panavia SA (Kuraray)
Unicem (3M ESPE)

De Munck et al., 2004

U200 (3M ESPE)

3. Cements
3.2. Material of choice

According to the substrate:

Metal cores
Resin composites (fiber posts)

Tooth substrate

3. Cimentos
3.2. O material de escolha

Metal

Resin composites

Tooth

Glass-ceramic crowns

Thin Veneers, Inlays, Onlays of porcelain or glass-ceramic

Polycrystalline crowns

Thick Crowns, Inlays e Onlays of porcelain or glass-ceramic

Polycrystalline crowns

Metal cores

Glass-ceramic crown

Conventional resin cement+


Self-etching primer (MDP)

Self-adhesive
Conventional resin cement+
Self-etching primer (MDP)
Chemical bond to metallic oxides of the post
Good hybrid layer on remaining dentin tissue

Self-adhesive
Easy to use
Less technique sensitive

Metal cores

Polycrystalline crown

Cojet
Synergic effect of Cojet+ silane + MDP
Chemical bonding to metallic oxides

Good hybrid layer with remaining dentin

Conventional resin cement+


Self-etching primer (MDP)

Substrate resin composite or tooth


Conventional resin cement photo-

Thin Veneers, Inlays, Onlays of

activated only.

Archegas et al., 2011

porcelain or glass-ceramic

Color change (Delta E, Lab)

Color change as a function of the cement


3

0
Rely X ARC

Variolink II
DUAL

Rely X Veneer Variolink Veneer

Filtek Flow

S FOTO only.
Photo-cured

FLOW

Celso Porto et al.

Substrate resin composite or tooth

Thick Crowns, Inlays e Onlays of


porcelain or glass-ceramic

Conentional resin cement dual-cure


Self-adhesive (small area of dentin available)

Luhrs et al., 2010

Substrate resin composite or tooth


Polycrystalline crowns
Synergic effect of Cojet + silane + MDP

Conventional resin cement +


Self-etchng primer (MDP)
*Additional acid etching of enamel with

phosphoric acid is necessary

Y-TZP

Synergic effect of Cojet + silane + MDP

Silane

MDP

1. Cojet
2. Silane application
3. Ceramic primer

Y-TZP
Y-TZP

3. Cements
3.3. The future

Universal adhesives

Universal adhesives
Dual resin cement+ Universal adhesive
Indicated for all materials

3
RelyX Ultimate

Cojet

Scotchbond Universal

(acid/primer/adhesive + silane + MDP)

Source: 3M

Lava Zirconia Crown Retention to Human Tooth


Detachment Load (N) after Thermocycling and Fatigue
800
700
600
500
400
300
200
100
0

Multilink Automix

Panavia F2.0

RelyX Ultimate

Burgess et al, Retention of zirconia crowns bonded with adhesive resin cements, AADR 2012, Abstract 156376

3M 2011. All Rights Reserved.

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