Handout for Chicago Dental Society meeting 2019
Raymond L. Bertolotti DDS, PhD
345 Estudillo Avenue, Suite 102
San Leandro, CA 94577, USA
Phone: (510)483-2411 FAX: (510) 652-8729
Please go to issue 33 for illustrations on zirconia adhesion bridges and ceramic onlays.
Adhesion Dentistry 2019
2. Adhesion to various substrates
2. Ray’s bonding recommendations for 2018
3. Ray’s composite recommendations for 2018
3. Re-attachment of tooth fragments
3. "Bite-formed" posterior composites…
6. Proper use of die spacing prevents sensitivity
6. Desensitizing cervical areas
6. Porcelain repairs
6. Fracture in porcelain only, no metal exposed
7. Porcelain fracture with some metal exposed, low stress
7. Porcelain fracture with substantial metal exposure
8. The non-crown
9. Temps on non-retentive preps
10. Bonding indirect restorations
10. Bonding crowns and inlay/onlay with Panavia F 2.0
12. Bonding crowns and inlay/onlay with StarFill 2B
12. Adhesion bridges
14. Cerec bonding and IDS
14. Ceramic failure data
15. Selected references
Adhesion to various substrates
• Enamel: phosphoric etch and rinse, adhesive (ideally Photo Bond or Prelude #2)
• Dentin: phosphoric etch and rinse or self etch, enamel-dentin adhesive (Prelude SE, Clearfil SE Protect, Clearfil SE Bond)
• Pressed ceramic: HF etch, silane, Panavia F 2.0; or Al2O3 sandblast (no HF), Clearfil Porcelain Bond Activator mixed 1:1 with Prelude #2 or Clearfil Photo Bond
• Porcelain: HF etch, silane, unfilled resin (?), flowable composite (light cure) or Panavia F 2.0 (dual cure); or Al2O3 blast, Clearfil Porcelain Bond Activator mixed with Prelude #2 or with Clearfil Photo Bond or CoJet/Rocatec/SilJet plus silane
• Lab composite: Al2O3 sandblast and Clearfil Activator mixed with Prelude #2 or Clearfil Photo Bond or CoJet/Rocatec/SilJet plus silane
• Base metal: Al2O3 blast, Panavia F 2.0 or SilJet/CoJet plus silane
• Gold: Al2O3 blast, tin-plate or noble metal primer, Panavia F 2.0 or CoJet/Rocatec/SilJet plus silane
• Zirconia, Alumina or Spinell (non HF etchable ceramics): Al2O3 blast, Panavia F2.0; or CoJet/Rocatec/SilJet plus silane or even better, plus Clearfil Ceramic Primer; or Al2O3 blast and then Z Bond followed by ordinary resin cement such as Starfill 2B
Ray’s bonding recommendations for 2019
Class I, II, and V composites
Prelude SE (#1 and #2) OR Clearfil SE Bond. (For large Class V,
Preferably use Prelude #2 in total etch protocol)
Class III and IV Composites
Total etch and Prelude #2 only OR total etch and Clearfil Photo
Indirect restorations that require dual-curing (eg. crowns)
Panavia F 2.0 (Normal set: ED Primer; Slow set: total etch, Microprime G, Photo Bond) OR Prelude SE with Link, then dual cure composite such as Starfil 2B or Variolink 2 (Panavia F 2.0 is OK but fast setting).
Indirect restorations that are light curable (eg. porcelain veneers)
Total etch, Clearfil Photo Bond, and Accolade PV
OR total etch, Prelude #2 only, Accolade PV.
Bonding to existing porcelain or composite
Al2O3 sandblasting followed by Clearfil Photo Bond mixed with
Clearfil Porcelain Bond Activator OR Prelude #2 mixed with Clearfil
Porcelain Bond Activator
Bonding to existing metal
Al2O3 sandblasting followed by Panavia F 2.0 or Photo Bond (on noble
metals: tin-plate or apply Tokuyama Metaltite after sandblasting or
switch to CoJet/Siljet plus silane.)
Ray’s composite recommendations for 2019:
Universal anterior/posterior, sculptable, "nano" spherical composite
Estelite Sigma Quick, favorite shades: A1, A2, OA2, OPA2, Bleach
(Omnichroma is a new version of Estelite, worth trying.. It has amazing shade change technology.)
Microfilled flowable composite (for class V or facial enamel replacement)
Aria, favorite shades: Incisal, A2
Flowable hybrid radiopaque composite (for first increment and up to
enamel): Accolade SRO, favorite shade: A2
Veneer bonding composite
Accolade PV with matching Try-in Composite (Clearfil Photo Bond makes it
Core buildup and base/blockout composite for Cerec
Clearfil Photo Core
Metal(or stain) blockout:
Accolade OP Mask, shade Tooth Color (A-2)
Re-attachment of tooth fragments
It is wise to do a "try-in" first! Do not use composite! Just use bonding agent on both tooth surfaces. If there is a chip or other defect, fill it in with flowable composite after reattaching the fragment. A microfilled composite (Aria (Danville), Renamel Flow (Cosmedent)) would be best for the fill-in since it maintains an enamel-like gloss and resists wear. It is wise to use a dual-curing bond since light may not penetrate the entire tooth easily, especially in thick areas.
Prelude SE technique: Total etch with phosphoric acid, wash, dry to dampness or remoisten dry surface, Apply Adhesive (#2) on both sides, air thin Adhesive, apply Link (#3)to only one side, quickly seat and light cure. (Prelude with Link will dual cure so do not worry about thorough light curing.)
Clearfil SE Bond technique: Apply SE Bond Primer for 20 sec, air dry, apply SE Bond "Bond" to both sides, seat and light cure very well.
"Bite-formed" posterior composites, used also for margin elevation…
A product specific technique for self-etching Clearfil SE Bond or Prelude SE
1. Place rubber dam or otherwise isolate.
2. Cut conservative prep (Fig. 1), using Caries Finder or Caries Detector to guide prep and caries removal. Stop at “pink haze” on the pulpal floor. Small bevels on the occlusal margin are generally desirable to prevent white line formation. If the marginal ridge is not fractured or cracked, consider cutting a “tunnel” prep, leaving the marginal ridge intact.
3. An optional but highly desirable first step is to use air abrasion to clean and roughen the prep after caries removal.(Fig. 2) If using MicroPrime G for protection against MMP’s, apply it and let dwell for 10 seconds and then suction off excess while blowing air. Avoid soft tissue contact.
4. Apply Prelude Primer(#1)or SE Bond Prime to dry or damp enamel and
dentin for 10 sec. (SE Bond Prime requires 20 sec.) (Fig. 3) These are
minimum times, longer is OK; agitation improves it. Take care that
the occlusal margin remains wet with the liquid primer. It is
not necessary to light cure the primer (It’s too thin to polymerize, due
to oxygen inhibition).
Note: the matrix may be applied before or after placing the bonding
agent. Shown here is placement before. With Clearfil adhesives, the
adhesive may bond to the metal matrix; with Prelude SE this is not a
Figure 1 Figure 2 Figure 3
5. Air dry only (no wash).
6. Apply Prelude Adhesive (#2) or SE Bond “Bond” with a clean Microbrush.
SE Bond should be wicked off with a dry Microbrush to avoid creating a
thick, radiolucent layer AKA “Clearfil caries”. Avoid air thinning SE
Bond (contrary to the manufacturer's instructions) since it may over-
thin the Bond layer on the margins and leave radiolucent pools in
corners. Prelude need not be wicked, just air dried to evaporate
7. Light cure the Adhesive/Bond layer (light cures the primer too).
8. Place Danville long or short Contact Matrix or a similar sectional
matrix if not done previously. Wedge if the gingival margin needs to be
closed. The Danville “elastowedge” (actually called the Contact Wedge)
is nifty when there is a long tooth or a root concavity. (Fig. 4) If a
wood wedge is used, it is sometimes best to invert the wedge, "apex
down", or use a round toothpick instead. When placed apex upward, the
wedge tends to distort the contour of the matrix and it might even open
9. Add Danville Contact Ring or MegaRing. (Fig. 5) The converging
tines of the Danville rings allow placement above the wedge with
good retention and matrix adaptation.
10. Apply a thin coat of light cure flowable composite (Accolade SRO recommended) with needle tip to cervical margin only. Cure this layer. Then add more flowable composite to build a marginal ridge to full height. Cure increments as necessary, never exceeding 2 mm per increment. (Fig. 6)
Figure 4 Figure 5 Figure 6
11. Place a thin layer of flowable composite to the pulpal floor (if
not already slopped on there!). Light cure again. Now add more
flowable to the level of the enamel but not onto the enamel to avoid
“coupling” the dentin and enamel. (Clearfil Photo Core, rather than
Flowable composite, is a nice material for thicker increments.) Light
12. Remove rubber dam if used.
13. Remove matrix. A MegaGrip forcep may come in handy here.
14. Mark occlusion (Fig. 7) and adjust the marginal ridge to allow
full CO closure. (Fig. 8) You now have a class I cavity to fill!
15. Wash and dry prep. Optionally, place a layer of bonding agent to
re-wet prep and composite surface. Place light cure posterior
composite (such as Heliomolar for best wear resistance, AP-X for
best strength, Estelite Sigma Quick for best esthetics and handling),
slightly overfilling, taking care to insure all margins are
covered. (Fig. 9) One increment will usually suffice for the “enamel”
layer. Saliva will not displace the composite; just be sure that the
margins are closed before exposing to saliva.
Figure 7 Figure 8 Figure 9
16. Place a glycerine gel (Danville’s translucent blue Liquid Lens is
ideal) on the occlusal surface of the composite. (Fig. 10)
17. Have patient bite into CO. While in CO, is sometimes possible to
trans-enamel cure from the buccal. (Fig 11) The bite will
establish the occlusion, leaving only some flash of composite to
18. Have the patient open and light cure from occlusal. A "soft start"
cure (150-200 on meter for at least 10 sec, then stronger light)
decreases stress in the composite.
19. Finish and polish. I like a Raptor diamond to add grooves, then
Vivadent’s Astropol cups and wheels to final polish.
Figure 10 Figure 11 Figure 12
Bite-formed posterior resin composite restorations, placed with a self-etching
primer and a novel matrix, Bertolotti RL and Laamanen H, Quintessence
International 1999; 30:419-422.
There are three variations, depending on how much porcelain is missing, if metal is exposed and if the repair area is under high stress.
Fracture in porcelain only, no metal exposed
(Repair with new porcelain, then bond porcelain to porcelain;
new veneer, sectional veneer, or reattachment of fractured porcelain)
Generally the repair will fail if the source of fracture is a flexible metal substructure. (In that case, use the cast metal/porcelain technique below.) If a traumatic fracture, this procedure is usually successful.
1. Etch new veneer surface with HF in lab (or sandblast at chairside, avoiding damage to margins by pinching margins with fingers).
2. Prepare intraoral surface by sandblasting (Danville ERC Microetcher with 25 or 50 micron aluminum oxide) until it looks “frosted”.
3. Liquid phosphoric acid wash of both porcelain surfaces for 5 sec.
4. Wash and dry.
5. Clearfil Porcelain Bond (Photo Bond plus Clearfil Porcelain Activator)
or Prelude #2 plus Clearfil Porcelain Bond Activator to both surfaces.
6. Bond with Starflow, Accolade or another (translucent) flowable composite if light curable or a dual curing composite such as Panavia F 2.0 (TC shade) or Starfil 2B if not light curable.
Porcelain fracture with some metal exposed, low stress.
(also endo opening in crown)
These are successful only for low stress situations such as near margins (or endo opening). (For high stress, remove porcelain from the failed unit and proceed as for substantial metal exposure, detailed below.)
A product specific technique for "Clearfil Porcelain Bond" (which is
Photo Bond mixed with Clearfil Porcelain Bond Activator (a 3 drop mix)
or Prelude #2 mixed 1:1 with Clearfil Porcelain Bond Activator)
1. Create finish bevels in porcelain with a diamond.
2. Sandblast both metal and beveled porcelain with 25 or 50 micron A1203.
3. If noble metal (other than non-precious), tin plate the sandblasted metal. Alternatively use Metaltite or Alloy Primer. Another alternative, use CoJet/Siljet and disregard the following steps 4 and 5.
4. Apply ordinary phosphoric acid etching agent to the beveled porcelain (The porcelain doesn't "etch" - but surface chemistry is altered by addition of a hydrogen atom to the silica network). Wash and dry. (If some acid gets on the tin-plated metal, no problem.)
5. Apply Clearfil Porcelain Bond (Photo Bond plus Activator), mixed according to the manufacturers directions, to both the metal and porcelain. Gently air dry for 2-3 seconds.
6. Place Accolade OP Mask (in suitable shade over metal areas present and light cure well. This product is critical for good esthetics. Be sure no metal shows thru the opaquer. A few thin coats, each light cured, is best for good cure and opaquer coverage.
7. Place composite resin, light cure and finish in the usual manner.
Porcelain fracture with substantial metal exposure:
These require overlay castings with new porcelain applied, adhesion metal to metal. May be used for single unit, multi unit, even fractured PFM bridges, with a two unit casting spanning the fractured section.
1. Remove any remaining porcelain and prepare failed unit for an indirect (lab) repair with a path of draw.
2. Make an impression and pour casts.
3. Cast a repair coping to overlay the failed unit. Apply porcelain or other esthetic veneering material. (Rexillium III or IV, non-precious alloys, allow the thinnest and strongest castings.)
4a. If using base ("non-precious") metal repair casting:
Sandblast the inside of the repair casting with 25 or 50 micron A1203.
4b. If using noble metal repair casting:
Preferably Al2O3 sandblast and then tin plate the interior of the repair casting after all adjustments and try-ins are completed. If tin plated in advance, protect tin-plated surface with Photo Bond prior to try-in. Blow the Photo Bond thin by directing a stream of dry air over the Photo Bond to prevent significant film thickness.
5. Bond repair casting with Panavia F2.0 to a suitably prepared intraoral surface (A1203 sandblasted if base metal or preferably Al2O3 sandblasted and tin-plated if noble metal. Alternatively, use Metaltite or Alloy Primer after sandblast). Use etching and then Photo Bond if any tooth structure is involved in the bonding location since Panavia alone does not bond well to dentin. Use Clearfil Porcelain Bond Activator plus Photo Bond if porcelain is involved. The Activator will not harm the tooth bond.
Alternative: CoJet/Siljet covered by either silane or Clearfil Ceramic Primer and then dual cure composite such as Panavia F2.0 or Starfil 2B.
When we consider that remaining dentin thickness correlates with need for subsequent endodontic treatment, the preferred treatment option often is one which relies on minimal tooth reduction. Adhesion, with less need for tooth reduction, is a highly desirable shift away from tooth preparation for mechanical retention. Metal or pressed ceramics such as E Max may be utilized. (Zirconia is best avoided.) When E Max is supported by sufficient enamel, its strength is about 75% of zirconia.
Temps on non-retentive preps
For non-retentive preps, "spot bonding" is used to retain the temps yet make them easily removable at the final bonding appointment. This is the method suggested by Dr. Tom Hughes.
1. Make a preliminary impression with a fast set VPS such as Danville's Monophase, which works best in a quadrant, closed bite “triple” tray.
2. After prep is completed, using a Microbrush, cover prep with Nogenol or TurboTemp 2 Cement mixed with 10-20% vaseline (this makes a low viscosity, easy to air thin, and slower set material). Thin the mixture with air. (Fig. 2) Regardless of its name, the "temporary cement" is actually a separating medium (it is not an adhesive cement!) so the temp can be easily removed at the seat appointment.
3. Set the cement with a fine mist of air/water spray from a distance.
4. Air abrade with Al2O3 a small "bond spot" in the center of the occlusal.
This should be 10% or less of the surface or just be more precise in brushing to leave a hole. (Fig. 2).
Fig. 1 Fig. 2
5. Form Turbo Temp 2 or similar products with the pre-op closed bite impression and let it set completely. There is no need for a bonding agent if the bond spot is on composite. TurboTemp 2 will bond well to the composite. If on tooth, place Photo Bond on the bond spot (no phosphoric etching used). The Turbo Temp will bond to the Photo Bond.
6. DO NOT REMOVE THE FORMED AND SET TURBOTEMP 2 from the prep. (This way the interprox and occlusal contacts are exactly the way they were before the prep.)
7. Should the temp come off when the pre-op impression is removed, place StarFlow or Accolade in the temp, reseat and light cure.
8. Clean up flash with Retract instrument and/or Bard Parker blade.
9. At the next appointment, pry off the temporary. If you used Photo Bond without etch, it will most likely come off the tooth clean.
10. In any event, clean up the cement debris with a Microetcher before final bonding.
Variation suggested by Dr. Russ Beggs: Place a spot of Photo Bond on the center of the occlusal, light cure it. Utilizing the preliminary impression, form the TurboTemp 2 directly against the Photo Bond. After removing the impression, light cure Photo Bond through the TurboTemp 2. Clean up flash with Retract instrument and/or Bard Parker blade but do not remove the temp. This Beggs method is not good if there is significant composite exposed on the tooth since too much Turbo Temp 2 will be bonded.
Bonding indirect restorations
(E Max, Empress, Procera, Lava, Bruxzir, etc.)
1. Adhesive built-in cements
Bonding of tooth colored materials with adhesive cements like Panavia F2.0 makes bonding easy. The built-in adhesion monomer (MDP) provides direct adhesion to metal and non HF-etchable oxide ceramics (zirconia and alumina). HF etchable ceramics, silica based, generally require addition of a silane after HF etching. Examples are: Empress, Wolceram, E Max and feldspathic porcelain. These are internally etched with HF in the lab and silaned at chairside. I place silane before try-in and protect the silane with a layer of light curing bond blown thin but of course, not cured! Should you get saliva on unprotected silane, clean it off with phosphoric etch and rinse. Clean Bruxzir, Procera, Inceram Alumina, Inceram Zirconia, InCeram Spinell and 3M Lava are bonded by Panavia F2.0 (or Panavia 21) without any primer or silane. Just Al2O3 sandblast and then apply Panavia. Silane is to be avoided here! It gets in the way of direct adhesion.
(Note that Panavia V does not have the adhesive monomer built in!! It should probably not be called Panavia!!)
2. Non-adhesive "composite cements"
Some low film thickness composites can provide excellent adhesion if a suitable primer is used on the restoration. One way is to use Clearfil Ceramic Primer on sandblasted ceramic. Another way is to use Z-Prime (Bisco) or Z-Bond (Danville) on sandblasted zirconia or alumina. Then a "non-adhesive" dual-cure composite may be used in place of the adhesive Panavia F2.0. Two favorite brands are Variolink 2 (Vivadent) and Starfill 2B (Danville). (Panavia V falls into this class.) Recent research showed that a core composite, Rock Core by Danville, actually had a lower film thickness than both Variolink 2 and Starfill 2B so it should work fine too.
Note about silanes:
Silanes differ in the method of application. I prefer Danville's S-Bond or 3M's Rely X silane (formerly ScotchPrime) since they only need be applied (without acid washing first) and dried. I prefer to protect the internally treated, silanated surface at try-in with a film of Photo Bond, blown thin but not cured. The dual-cure of Photo Bond eliminates worries about light curing completely. Photo Bond is thin enough to be insignificant in affecting fit. Alternatively, you may also use Photo Bond mixed with Clearfil Porcelain Bond Activator (a specialized silane) making a 3 drop mix. After try-in, the surface can be water rinsed and dried.
Bonding crowns and inlay/onlay with Panavia F2.0 (TC shade)
1. Anesthetize patient if very cold sensitive (self-etching ED Primer does
not usually require anesthesia).
2. If desired to loosen contacts, apply a MegaRing and remove after a few minutes.
3. Remove temporary restoration and clean with pumice (not prophy paste) or gently Al2O3 sandblast tooth.
4. Unless "high and dry", place rubber dam or retraction cord (Ultradent's #0 Cord and their packers are preferred), preferably saturated with Visine. Specifically avoid ferrous sulfate to avoid bond problems and iron sulfide black stain, “black skuz”.
5. Try restoration onto tooth very carefully. Do not check occlusion on E Max before cementation. It is weak at this time. To locate problem areas, G.C. Fit Checker, a white silicone works well. (It is best that Fit Checker not be placed on the etched surface without a protective resin layer present. Easiest is to place a layer of Clearfil Porcelain Bond (Photo Bond plus Clearfil Porcelain Bond Activator) and air thin.
6. Properly clean and condition the internal surface of the restoration. If protection is not done, gentle sandblasting works well to remove contamination but will destroy HF etching (no problem for alumina and zirconia since no HF is used). If HF etching is destroyed, just use Clearfil Porcelain Bond (Photo Bond plus Clearfil Porcelain Bond Activator)on the sandblasted surface.
7. Pumice tooth or use Al2O3sandblasting to remove all traces of try-in resin.
8. Optionally, place MicroPrime G or MicroPrime B (keeping G off soft tissue, being very careful here), let dwell 10 seconds, dry. Apply ED Primer, 30 sec minimum, then dry thoroughly.
9. Place Panavia F2.0 on the restoration, taking care to have plenty and being sure all internal surface is covered with no voids.
10. Seat restoration gently, watching for a bead of excess Panavia at the margins to assure void removal.
11. It is best to "gel" the Panavia bead with a brief light cure, perhaps 2-3 seconds. Then the gel can be removed with a curette or floss but moisture or blood will not displace the Panavia at the margin areas. If not light gelled, wipe off the excess Panavia with a brush. Then spot cure on buccal and lingual margin. Now you may floss contacts downward or pull a Tofflemire band through and leave it there while curing. Apply Oxyguard 2 or preferably light cure the margin areas. Shade OP (opaque) Panavia F 2.0 will not cure with a light so you must use Oxyguard at the margins if using the OP shade.)
12. After 3 minutes, wash off Oxyguard 2, if used (required for OP shade).
13. Finish restoration to tooth using: Horico 4mm Ribbon Saws or Axis Separator to break contact, if necessary. Flexis disks on all accessible margins. Any of the following on margins with limited access: D Fine Double diamond, Shofu points, micro-fine diamonds, GC strips, usually 600 grit. Polish.
14. Mark occlusal contacts. Ideally, the final check is done with TapeTrix Teflon. Adjust if necessary and re-polish. Brasseler's Dialite/Truluster polishing system works well for most materials.
Bonding crowns and inlay/onlay with StarFill 2B
While StarFill 2B was designed for other applications, it is apparent that it works very well for adhesive cementation procedures. Its film thickness (ISO 4049 test) of 22 microns is in the range of other products intended for adhesive cementation of crowns and inlay/onlay. Panavia F 2.0, for example, tests at 24 microns while Clearfil Esthetic Cement measures 22 microns.
StarFill 2B compares to Variolink 2,Clearfil Esthetic Cement, and Panavia V as opposed to Panavia F2.0. Panavia F2.0 has adhesive monomers built in, the others do not. So like with Variolink. Esthetic Cement, and Panavia V suitable restoration primers must be used with Starfil 2B.
Tooth: While any dual-cure adhesive should work, Danville recommends Prelude SE, used with bottle #3, Link.
Porcelain and other HF-etchable ceramics: After HF etching, a silane such as Danville S-Bond should be applied.
Zirconia and Alumina (these are not HF etchable): Al2O3 sandblasting followed by application of Danville Z-Bond or Bisco Z-Prime.
Metal: Metals should be Al2O3 sandblasted and then tin-plated or alternatively primed with a dedicated primer such as Tokuyama's Metaltite. (Caution: this is a reasonable bond but not as strong as Panavia on tin-plated metal so it should not be used for critical applications. It is expected to be adequate for crowns.)
Adhesion Bridges (porcelain-fused-to-metal)
Metal: The metal alloy and the design of the retainer greatly influence the long term function of adhesion bridges. Clinical success has proven that shallow retentive/stiffener grooves and stiff metal are the keys to success. (I use Shofu size 170 Hybrid Point (Shofu product number PN0921-3, available from Schein) to place the grooves.) Existing restorations should generally be removed and can be a part of the retention and resistance design.
Non-precious nickel chromium alloys (such as Rexillium III or IV), when Al2O3 sandblasted, have the advantages of direct adhesion to Panavia F2.0 and increased stiffness compared to precious alloys. (It takes 1.4x the thickness of nickel chromium alloy to get equal stiffness in a gold alloy and even more for palladium.) For anteriors, use the opaque shade of Panavia(OP) to prevent metal show-through.
TRY-IN: Panavia f2.0 “B pastes” have the color, “A pastes” are universal, mixed with any B paste. You may try-in with B paste on Al2O3 blasted metal. Just remove most of it with a brush and apply the A+B mix. The residual B paste will cure when the A+B mix touches it (“diffusion polymerization”).
These metal designs follow those proposed by Professor A. Yamashita. An imaginary line is drawn from the center of the proximal surface at the side of the missing tooth through the abutment tooth axis. Grooves (channels) are cut outside this line, mostly in enamel. A bar connects the grooves and forms the incisal margin, generally ending the retainer short of the incisal margin (ignoring the channel there) except in perio cases where I may use the incisal channel. A cantilever design is used to replace lateral incisors. It is essential to have the promixal grooves (channels).
All-ceramic adhesion bridges
The most reliable ceramic is zirconia, monolythic (Y3) and not the translucent variations. Alumina bonds even better than zirconia but the ceramic will sometimes fracture in the connector area. Zirconia will de-bond but generally not fracture so that it can usually be re-bonded.
The following design follows the advice of Professor Matthias Kern of Germany. Note that for metal, Kern uses grooves much like those in the Yamashita design but drawing more lingually. Yamashita’s grooves draw more incisally and omit the pinhole. Kern’s design for zirconia and alumina does not use grooves. Only the pin hole is used for indexing. Kern also uses a “box” to reinforce the connector area.
Simple and reliable bonding is achieved by Al2O3 sandblasting followed by application of Panavia F 2.0 (a dual cure) or Panavia 21 (a self cure). Do not use Panavia SA. Panavia TC shade is preferred for esthetics. You may use Panavia V but be sure to use the primers as directed. Silane application is contraindicated on zirconia. Do not expose the zirconia bonding area to phosphoric acid. Should you do this, remove the damage with Al2O3 sandblasting. I do not wash after blasting but if you do, wash with 99% isopropyl alcohol as recommended by Kern.
Kern’s data shows that an even stronger bond to the ceramic is achieved by using CoJet and Clearfil Ceramic Primer on the CoJet treated surface. However just Panavia appears to be sufficient since the reported retention rates exceed 95% at 10 years.
Cerec bonding and IDS – ideally done with Prelude SE
- Prepare tooth by removing caries and any structurally compromised tooth structure.
- Apply primer (Prelude Primer #1), air dry, and apply bonding agent (Prelude Adhesive #2), dry and light cure.
- Apply a layer of Clearfil Photo Core (or Accolade SRO) and light cure.
- If any areas of Photo Core (or Accolade SRO) will not have the oxygen inhibited layer removed by refining the preparation, apply Liquid Lens and light cure again.
- Make the final cavity preparation, cleaning bond off the enamel margins for optimal adhesion.
- Optical impression.
- Gently Microetch with 27 micron alumina or SilJet to remove the powder.
- Etch preparation with liquid phosphoric acid, wash, dry.
- Apply Prelude #2 (even better mixed 1:1 with Clearfil Porcelain Bond Activator) to all surfaces. Blow dry.
- Apply Panavia F 2.0 (using TC, tooth color shade) to restoration (HF etch and silane the restoration before applying the Panavia)
- Seat restoration, being sure to avoid trapping air.
- Brush off excess Panavia F 2.0 and light cure the margins.
Ceramic Failure Data
Data courtesy of Ken A. Malament DDS, Boston, MA
1. Pulp reactions to different preparation techniques on teeth exhibiting periodontal disease. Zollner A and Gaengler P, J Oral Rebibil. 2000 Feb;27(2):93-102. The severity of endodontal reactions depends more on remaining dentin thickness than on the type of preparation.
2. Biocompatibilty of Clearfil Liner Bond 2 and Clearfil AP-X system on nonexposed and exposed primate teeth. Akimoto et al, Quint Inter 1998; 177-188. There was no difference in pulpal inflammation between Clearfil Liner Bond 2 / AP-X and calcium hydroxide controls in either class V or class I cavities at various time periods.
3. Contraction stress of flowable composite materials and their efficacy as stress relieving layers. Braca RR, JADA 2003:134:721-728. There was no significant difference in stress on the bond between flowable and non-flowable composites. Microfills produced lower strain than conventional fills (both flowable and non-flowable.)
4. Bite-formed posterior resin composite restorations, placed with a self-etching primer and a novel matrix. Bertolotti RL and Laamanen H, Quint Inter 1999; 30:419-422. This procedural paper focuses on tight and anatomically correct contacts, post-operative sensitivity, occlusion, and clinical efficiency.
5. Factors and prevention of pulp irritation by adhesive composite restorations. Fusayama T, Quint Inter 1987:18:633-641. A classic paper which explains why insufficiently adhesive bases lead to post operative bite-pressure sensitivity.
6. Glass-ionomer cement restorations and secondary caries: a preliminary report. Mjor IA, Quint Inter 1996:27:171-174. The clinical diagnosis of secondary caries is the most common reason for failure of glass ionomer restorations in a survey from general dentists. Glass-ionomer did not survive as long as composite and amalgam restorations.
7. An in vivo evaluation of hemorrhage control using sodium hypochlorite and direct capping. Hafez AA et al, Quint Inter 2002;33:261-272.
Normal soft tissue reorganization and dentinal bridge formation were observed in 86% of pulps treated with sodium hypochlorite and All Bond 2 /composite or One Step / compomer. Good review of Dycal research.
8. Adhesive monomers for porcelain repair. Bertolotti RL et al, Int J Porosthodont 1989; 2:483-489. Adhesion strengths to many surfaces are reported and protocols are given for intraoral porcelain repairs.
9. Adhesion monomers utilized for fixed partial denture (porcelain/metal) repair. Bertolotti RL and Paganetti, Quint Inter 1990;21:579-582.
A fractured “solder joint” in a 10 unit bridges is repaired intraorally. Surface preparation techniques and adhesive materials are discussed.
10. Intraoral metal adhesion utilized for occlusal rehabilitation. Bertolotti RL et al, Quint Inter 1994;25:525-529. An occlusal rehabilitation is completed with adhesion and minimal to zero invasion. Illustrated is gold to gold adhesion and the necessary intraoral procedures.
11. Fatigue span of porcelain repair systems. Llobell A et al, Int J Pros 1992;5:205-213. Only All Bond and Clearfil Porcelain Bond did not fail before reaching the 2,000,000 cycle test limit. “Clearfil Porcelain Bond (uses no HF) undoubtedly appears to be the simplest system to use”.
12. Two unit cantilevered resin-bonded fixed partial dentures. Botelho et al.;Inter J Pros 2000;13:25-28. Found good results with cantilevered adhesion bridges, bonded with Panavia and using Yamashita prep design.
13. Fracture load and mode of failure of ceramic veneers with different preparations. Castelnuevo et al, J Pros Dent 2000;83:171-180. Found strongest veneer to have 2 mm of unsupported incisal porcelain and butt joint on lingual (lingual chamfer did not add strength). This paper is reprinted in the Calif Dental Journal, Feb 2004.
14. Bonding of glass infiltrated alumina ceramic: Adhesive methods and their durability. Kern M and Thompson VP, J Pros Dent 1995;73:240-249.
Neither HF etching nor adding silane resulted in adequate bond to Inceram. Two methods worked: Panavia and Rocatec (presumably also CoJet would work).
15. The effect of a “Resin Coating” on the interfacial adaptation of composite inlays. Jayasooriya PR et al., Operative Dentistry 2003; 1 28-35.
Looks at "immediate dentin sealing" and the resulting effects on gaps between restoration and tooth.
16. Longevity and reasons for failure of sandwich and total-etch posterior composite resin restorations. Opdam NJM et al., J Adhes Dent 2007; 9:469-475. Class II composites placed with resin modified glass ionomer lining showed more frequent fractures than fillings place with total-etch technique (SA Primer and Photo Bond). Survival rates at 9 years: 88.1% for total etch, 70.5% for RMGIC lining.
17. Factors contributing to the incompatibility between simplified step adhesives and self-cured or dual-cured composites. Part II. Tay F et al; J Adhes Dent 2003;5:91-105. Shows pulpal fluid permeability through adhesives and how it affects composite/adhesive compatibility.
18. Nightguard vital bleaching of tetracycline stained teeth: 90 months post-treatment. Leonard RH et al, J Esthetic Restorative Dent 2003;15: 142-153. Some very good results for extended (6 months) bleaching times. Good list of references on bleaching.
19. Effect of three adhesive adhesive primers for a noble metal on the shear bond strengths of three resin cements. Yoshida et al, J Oral Rehab 2001;28:14-19. Tested Panavia F and Bistite with Alloy Primer or Metaltite primer. Generally Metaltite performed better, both with Bistite and with Panavia F.
20. Sealing Ability of Packable Resin Composites in Class II Restorations, Fabianelli A et al., J Adhes Dent 2003, 5(3):217-23. The application of a thin layer of a flowable composite at the cervical margin as a liner underneath the packable composite enhanced the marginal adaptation of the restoration. The use of a self-etching primer to condition the dental substrate resulted at the occlusal margin in greater microleakage than when phosphoric acid was applied.
21. Immediate dentin sealing supports delayed restoration placement. Magne P et al., Journal of Prosthetic Dentistry 2007:98(3):166-174. Control (C) specimens were prepared using an immediate bonding technique and direct composite Z100 restoration. Immediate dentin sealed (IDS) teeth had provisional restorations (Tempfil inlay) placed for 2 weeks (IDS-2W), 7 weeks (IDS-7W), or 12 weeks (IDS-12W) before restoration placement. (Final bonding procedure used sandblast and more bonding agent.) Delayed dentin sealing (DDS) used an indirect approach without dentin pre-bonding. Both C and IDS-2W groups demonstrated interfacial failure that was typically mixed with both areas of failed adhesive resin and areas of cohesively failed dentin while IDS-7W and IDS-12W failed consistently between the existing resin coating (used during IDS) and the overlaying composite resin. Failures in DDS group were all interfacial and purely adhesive. C and all IDS groups were not significantly different and exceeded 45 MPa. DDS groups exhibited lower tensile bond strength than all others.
22. Cumulative effects of successive restorative procedures on anterior crown flexure: intact vs. veneered incisors. Magne P and Douglas W. Quint Inter 2000;31:5-18. Showed that tooth is far more flexible (about 2X) when all the enamel is removed than when only some or no enamel is removed.
23. Papathanasiou A, et al. Clinical evaluation of a 35% hydrogen peroxide in-office whitening system. Compendium 2002; 23(4):335-346. A nice summary of bleaching efficacy. (Although not peer-reviewed, you will find similar conclusions in detail in CRA Newsletter issues: April 2000, and March 2003.)
24. Bond strength to bovine dentin over 6 years, Burrow MF et al, First International congress on adhesive dentistry, Tokyo 2002, paper S-17.
The bond strength of Amalgambond Plus (total etch) decreases over 72 months while the bond strength of (self-etching) Liner Bond 2 showed no change.
25. Effect of eugenol-containing endodontic sealer on retention of prefabricated posts luted with adhesive composite resin cement Tyan AH and Nemetz H. Quintessence Inter. 1992 Dec;23(12):839-44. Findings of this study demonstrated a substantial decrease in retention of posts luted with Panavia composite resin cement in the presence of eugenol. Irrigation with ethyl alcohol (ethanol) or etching with 37% phosphoric acid gel was found to be effective in restoring the resistance to dislodgment of the posts, but alcohol produced the most consistent and reliable results.
26. Clinical evaluation of a composite resin system with a dentin bonding agent for restoration of permanent posterior teeth - a 3 year study, Roberts MW, Folio J, Moffa JP, Guekes AD, J. Pros. Dent 1992;67:301-306.
Showed that composite resin restorations outperformed amalgam restorations over the period studied. Note date of publication 1992; restorations placed in 1988 with “old-fashioned“ bonding, etc.
27. A two year clinical study of light cured composite and amalgam restorations in primary molars. Barr-Agholme M, Oden A, Dahllif G, Modeer T, Dent. Mater 1991;(7)230-233. Showed that the success rate of class II composite restorations were significantly higher than for class II amalgam fillings in primary molars.
28. Resistance to cusp fracture in Class II prepared and restored premolars. Gelb MN, Barouch E., Simonsen RJ. J Pros Dent 1986;(55)184-185. While both amalgam and composite restorations may restore some strength, only etched and bonded composite restorations return the tooth to a fracture strength as high or higher than that of sound, unprotected teeth.
29. The effect of restorative materials on cuspal flexure. Medige J, Deng Y, Yu X, Davis EL, Joynt RB. Quintessence International 1995;(26) 571-576. Show that a amalgam is totally incapable of restoring the physical integrity of a tooth weakened by a cavity preparation, while a properly placed composite totally restores the internal strength of tooth equal to or better than that of an intact tooth.
30. Micro-leakage of All-ceramic Crowns Using Self-etching Resin Luting Agents. Trajtenberg CP, Caram J, Kiat-amnuay S. Operative Dentistry 2008: (33-4)392-399. Showed Panavia F to have far less leakage than Unicem and Multilink after thermal cycling. Showed results with and without spacing.
31. Use of a Pressure Chamber to Compare Microleakage of Three Luting Agents. Lyons KM, Rodda JC, Hood JAA. Int J Prosthodont 1997; 10: 426-433. Zinc phosphate showed highest leakage and it developed quickest, glass ionomer about 50% of this, but no microleakage with resin (Panavia 21).
32. Flowable resin composites as filled adhesives: Literature review and clinical recommendations. Unterbrink GL and Liebdenberg. Quint Inter 1999; 30: 249-257. Flowable resin composites were used as an adhesive over thinned single component bonds.
33. Do Low-shrink Composites Reduce Polymerization Shrinkage Effects? Tantbirojn et al. J Dental Research 2011:(90) 596-601. Two low-shrink composites, despite having the lowest and highest total shrinkage values, did not cause significant differences in cuspal deflection. Deflection seemed most related to the combination of post-gel shrinkage and elastic modulus. Therefore, even for significantly lower total shrinkage values, shrinkage stress is not necessarily reduced.
34. Cell and tissue reactions to mineral trioxide aggregate (MTA) and Portland cement. Saidon J et al. OS OM OP OR Endod 2003;95:483-489.
MTA and PC show comparative biocompatibility when evaluated in vitro and in vivo. The Portland cement was sterilized by ethylene oxide.
35. Direct Pulp Capping With Mineral Trioxide Aggregate- An Observational Study. Bogen, G et al. JADA 2008;;39(3)305-315. Over an observation period of nine years, the authors followed 49 of 53 teeth and found that 97.96 percent had favorable outcomes on the basis of radiographic appearance, subjective symptoms and cold testing.
36. The “Bottom Line” on Bleaching 2008, Haywood VB, Inside dentistry 2008: 4(2)2-6. This is an excellent summary of all bleaching techniques and their outcomes.
37. Porcelain laminate veneers. A retrospective evaluation after 1 to 10 years of service. Part 2- Clinical results. Dumfahrt H and Schaffer H. Inter J Pros 2000;13:9-18 Survival rate of over 90% at 10 years.
38. Relationship between bond-strength tests and clinical outcomes. Van Meerbeek B et al., Dental Materials 2010, February:26 (2): 100-121. “Altogether, when bonding to enamel and dentin, selective etch of enamel followed by the application of the 2-step self-etching adhesives to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue.”
39. Durability of the resin bond strength to zirconia ceramic after using different surface conditioning methods. Wolfart M et al., Dental Materials 2006;23:45-50. Showed sandblasting followed by Panavia F to bond well to zirconia, far better adhesion than with Variolink II.
40. Influence of contamination on zirconia ceramic bonding. Yang B et al.
J Dent Res 2007, 86;749-753. Contamination that existed after try-in simulation was best removed by air abrasion with aluminum oxide. Confirmed zirconia bond with Panavia.
41. Influence of c-factor and layering technique on micro-tensile bond strength to dentin. Nikolaenko SA et al. Dental Materials 2004, 20, 579-585. Horizontal layers resulted in significantly higher bond strengths than did vertical or oblique layers.
42. Adhesive-composite incompatibility, Part II. Carvalho, R. M., et al, Journal of Esthetic and Restorative Dentistry, 17: 191, 2005. This article discuses reasons for selection of self-etch adhesives versus total-etch adhesives when bonding dual-cure composite resins.
43. Deep Margin Elevation: A Paradigm Shift. Magne P. Spreafico RC. Am J Esthet Dent 2012; 2:86-96. Proposed immediate dentin sealing and coronal elevation of deep margin using direct composite.
44. A systematic approach to deep caries removal end points: The peripheral seal concept in adhesive dentistry. Alleman D and Magne P. Quintessence Inter;43:3,197-208. Deals with caries removal end points in order to effectively bond to carious dentin and avoid pulp exposures.
45. Clinical reversal of root caries using ozone: 6-month results. Baysan A and Lynch E, Am J Dent 2007:20(4):203-8. Shows HealOzone to be effective on root caries.
46. Effect of ozone on non-cavitated fissure lesions in permanent molars. A controlled perspective clinical study. Huth KC et al, Am J Dent 2005: 18(4)223-228. This study presents some very important information on the risk factors for the patient, where ozone works and where it does not, in agreement with our clinical observations.
47. Assessment of the ozone-mediated killing of bacteria in infected dentine associated with non-cavitated occlusal carious lesions. Baysan A and Breighton D, Caries Res 2007;41(5):337-41. This study shows that ozone is not effective when there is too much tooth structure and/or debris in the way
48. Clinical reversal of root caries using ozone: 6-month results. Baysan A and Lynch E, Am J Dent 2007:20(4):203-8. The results show HealOzone efficacy on root caries where there is minimal tooth structure and/or debris in the way.
49. The inability of Streptococcus mutans and Lactobacillus acidophilus to form a biofilm in vitro on dentine pretreated with ozone. Knight GM et al, Australian Dental Journal 2008:(4):349-353. This study showed that the infusion of ozone into non-carious dentine prevented biofilm formation in vitro from S. mutans and L. acidophilus over a four-week period. 50. Inability to form a biofilm of Streptococcus mutans on silver fluoride- and potassium iodide-treated demineralized dentin. Knight GM et al, Quintessence Int 2009:(2):155-161. Demineralized dentin disks treated with AgF and AgF/KI prevented the formation of an S. mutans biofilm.
51. Treatment of deep carious lesions by complete excavation or partial removal, Thompson V et al., JADA 2008; 139 (6) 705–712. Three randomized controlled trials, one of which followed up patients for 10 years, provide strong evidence for the advisability of leaving behind infected dentin, the removal of which would put the pulp at risk of exposure.53. Load-bearing properties of minimal-invasive monolithic lithium disilicate and zirconia occlusal onlays: finite element and theoretical analyses. Ma L. et al., Dental Materials 2013 July:29 (7): 742-751. The load-bearing capacity of lithium disilicate can approach 75 % of that of zirconia when bonded to enamel. This is particularly true for ceramic restoration thicknesses of 0.6 mm to 1.4 mm, which is most pertinent to the occlusal veneers and onlays. In addition, the load-bearing property of lithium disilicate onlay becomes less sensitive to its thickness when supported by enamel, signifying its great potential for applications in minimally invasive dentistry.