Evaluation of rebonding strengths of Lithium Disilicate and

Feldespathic Veneers  debonded with an Er,Cr:YSGG Laser.

Ahmed Ibrahim Youssef a, Marwa Mohamed Wahshb, Norbert Gutknechtc, Talaat Mohamed
Samhand Ghada Abd El Fattah Abd El Sattare,
a Assistant lecturer, Fixed prosthodontics Department, Faculty of Dentistry, Misr
International University
b
Associate Professor of Fixed Prosthodontics, Fixed Prosthodontics Department, Faculty of
Dentistry, Ain Shams University
c
Department Director of the Department of Restorative Dentistry, Director of the Aachen
Dental Laser Center, Scientific Director of Academic Postgraduate Master Program "Master
of Science – Laser in Dentistry at the RWTH Aachen University
d
Lecturer of Fixed Prosthodontics, Fixed prosthodontics Department, Faculty of Dentistry,
Misr International University
e
Lecturer of Fixed Prosthodontics, Fixed prosthodontics Department, Faculty of Dentistry,
Ain Shams University

The Aim :
The purpose of this study was to evaluate the efficacy of wavelength transmitted laser peels in
the family of dental lasers of the erbium type (using a turbo handpiece) and its effect
on the topography of the selected ceramic surface, as well as the shear bond strength of
rebonded veneers.

Materials and Methods:

In this study, a total of 80 ceramic specimens were used. They were divided into two groups
(n= 40/group) according to ceramic material used, Group (A) lithium disilicate (IPS Emax),
Group (B) Feldspathic porcelain. (VITA MARK II). Each group was further subdivided into
two subgroups according to the cement curing mode (n= 20/subgroup): Subgroup (L) Light
cured resin cement, Subgroup (D) Dual cured resin cement, Each subgroup was finally
subdivided into two subdivisions according to applied tests (n= 10/subdivisions): Shear bond
strength (i) (control group). Scan electron microscope (ii). These subdivisions were of
importance, as the specimens of subdivision (i) will be demolished once subjected to shear
bond strength test. Er,Cr:YSGG (turbo handpiece) was used on all subgroups. Scanning
electron microscope were used to evaluate surface tomography and EDAX atomic
percentage, Universal testing machine (Instron, North America) was used to investigate the
difference between shear bond strength of control irradiated group and lased groups after
rebonding either cemented by light or dual cured resin cement in order to compare their
longevity and success rate. Data were analyzed statistically.

Results :
Scan electron microscope images revealed: The IPS Emax showed the typical lithium
disilicate crystals embedded in a glass matrix, rod shaped that are interlocked and haphazardly
organized. whileThe VITA MARK II showed a microstructure based on aluminum, potassium
and sodium based silicate with grains of about 4 µm, very porous material, described as
honeycombed surface.
EDAX atomic percentages : the initial baseline results are consistent with what the
manufacturer has said. The second examination carried out following laser irradiation with
these parameters for debonding revealed variances in chemical composition generally
compared to the reference groups, and even variations were discovered by altering the manner
of cement curing mode.
Shear bond strength : The results showed that ceramic (regardless of curing and rebonding)
had a statistically significant effect on mean shear bond strength. Curing (regardless of
ceramic and rebonding) had a statistically significant effect on mean shear bond strength.
Rebonding (regardless of ceramic and curing) had a statistically significant effect on mean
shear bond strength. The interaction between the three variables also had a statistically
significant effect on mean shear bond strength. Since the interaction between the variables is
statistically significant, so the variables are dependent upon each other.
Conclusion:
The Er,Cr:YSGG laser could be an effective and useful tool in debonding of lithium disilicate
and feldspathic ceramic veneers as it decreases the shear bond strength required for veneer
debonding.
KEYWORDS: laser debonding, ceramic veneers, shear bond strength, rebonding.
INTRODUCTION
The Smile was found to be one of the first traits that get recognized during interpersonal
interactions, where a beautiful smile was valued as high self-esteem. Dentistry has changed
dramatically over the past decades, from just the meaning of treating the pain of dental
disease to accomplishing the optimal standards of beauty. With all the influences of the media
that people get exposed to frequently nowadays, dental esthetics has become a challenge[1,
2].
There are different esthetic restorative materials available nowadays in dentistry, which may
be used directly and indirectly. The most popular restorative material is the porcelain laminate
veneers {Aguiar, 2010 #45}which are known to have various advantages for their ability to
bond to the tooth structure, low occlusal wear of opposing teeth, and on top of that its esthetic
characterization especially when done with layering technique[3].
The microstructure of ceramics determines the optical and mechanical properties of the
restoration. As the glass content increases, this gives superior esthetics but low mechanical
properties, on the other hand when the fillers increase the mechanical properties also increases
showing less translucency, To combine both strength and esthetic properties, a layering
technique was used by using a high strength core veneered with translucent porcelain,
monolithic restorations fabricated by CAD/CAM in case of Feldspathic porcelain and lithium
disilicate or monolithic lithium disilicate fabricated by heat pressed technology have been
suggested[4].
Materials frequently used for laminate veneers include Emax and Feldspathic porcelain those
types of veneers offers numerous benefits and features, Emax and Feldspathic veneers are
primarily made by CADCAM technology, which makes them highly durable. Moreover, these
come in thin layers, and this prevents the need for drilling teeth. This is the most impressive
feature of this type of veneer since teeth are preserved, unlike with conventional veneers[5].
However some localized failures could happen such as discoloration, microleakage, ditching
at the margins, or simple fracture, so it needs to be repaired or replaced, new technique of
porcelain laminate veneer debonding was recently developed by using Er:YAG laser
(Erbium‐doped: yttrium aluminum garnet) which was inspired by its applications on the
orthodontic ceramic brackets that started in the 1990s[6, 7].
Therefore, it seems worthwhile to investigate the surface properties and shear bond strength
of CAD/CAM blocks (VITA MARK II and IPS E-max) debonded by Er,Cr:YSGG laser
resembling porcelain laminate veneers to provide recommendations for the best clinical
procedure to be easily rebonded.
Materials & Methods:
1.Materials:
In this study, the selected wave length was applied on two ceramics. The surface topography
was analyzed at base line and after debonding, also the Shear bond strength was measured
after rebonding of lased veneers.
Table (1): The ceramic blocks in the study.

Chemical
Materials Clinical Lot
Code Classification Manufacturer content
tested Indications number
(wt. %)

56–64%
SiO2,
Veneers,
Feldspathic VITA 20-23% inlays, onlays,
VITA Al2O3,
VIT glass-matrix Zahnfabrik, anterior and 63050
Mark II
ceramic Germany 6–9% Na2O, posterior
crowns.
6–8%
K2O

Veneers,
inlays, onlays,
58–80%
anterior and
SiO2,
posterior
Lithium 11–19% crowns,
IPS Ivoclar Vivadent
disilicate based Li2O, anterior and
e.max MAX AG, X12057
glass-matrix posterior
CAD Liechtenstein 0–13% K2O,
ceramic implant
0–8% ZrO2 abutments,
three-unit
0–5% Al2O3
bridges up to
premolars.

Table (2) Mechanical properties of IPS e.max lithium disilicate

Property Unit of measure Value

Flexural strength MPa 360 ± 60

Chemical solubility µg/cm2 40 ± 10

Expansion Coefficient 500ºC 10-6K-1 10.45 ± 0.4

Table (3): Mechanical properties of Vita Mark II.

Property Unit of measure Value

Flexural strength MPa 154 ± 15

Young’s Modulus GPa 63.0 ± 0.5

Expansion Coefficient 500ºC 10-6K-1 9.4 ± 0.1

Table (4): Resin-based luting agents used in the study.

Luting agent Organic phase Inorganic phase Lot no.

4036103
TEGDMA, BisGMA,
Dual-polymerizing Silanized ceramic
dimethacrylate functionalized 4006490
(RelyX ultimate clicker) and silica particles
polymer, triphenyl antimony
( syringe)

8714TR
Light-polymerizing dimethacrylate functionalized Silanized ceramic
(RelyX Veneer) polymer, triphenyl antimony and silica particles
(ref)
2) Methodology:
Specimen grouping and study design:
In this study, a total of 80 ceramic specimens were used.
Divided into two groups (n= 40/group) according to ceramic material used into:
 Group (A) lithium disilicate (IPS Emax)
 Group (B) Feldspathic porcelain. (VITA MARK II)
Each group was further subdivided into two subgroups according to the cement curing mode
(n= 20/subgroup):
 Subgroup (L) Light cured resin cement
 Subgroup (D) Dual cured resin cement

Each subgroup was finally subdivided into two subdivisions according to applied tests (n=
10/subdivisions):
 Shear bond strength (i) (control group).
 Scan electron microscope (ii).
These subdivisions were of importance, as the specimens of subdivision (i) will be
demolished once subjected to shear bond strength test.

 Preparation of the ceramic samples:

Using a low speed, high precision diamond saw , the specified lithium disilicate and Vita
Mark II Ceramic blocks were sliced to dimensions of 10×10 mm and thickness of 0.7 mm.
The slices were cutted using an integrated coolant delivery system that flooded the samples
from both sides of the blade while tracking blade movement. The 0.7mm thick blade moved
linearly, providing a constant feed rate cutting of 14.7 mm per minute at 2500 rpm in 50 rpm
increments.then Furnace EP3010 programat, Ivoclar was used to crystallize the ceramic discs.

Table (6): Parameters used in the crystallization of ceramic discs.

Standb Closin Heatin Holdin Holdin Max Vacuu Vacuu Long

y temp g time g Rate g g temp Tem m On m Off time
(B) (s) Time (T) p. (V1) (V2) coolin
(C°) (mm:s (t) (H) (°C) (°C) (°C) g (L)
s) (°C/ (Min.) (°C) (°C)
min)

403 06:00 90 00:10- 830– 917 550 830– 710

07:00 85083 850
0-850
  Fabrication of acrylic blocks:
A special mold was prepared for each bovine tooth, the ice cube mold was used to be filled
with cold-cure acrylic resin; color-coded for ease of differentiation between groups. Vaseline
was applied on the molds before cold cure acrylic resin was poured to act as a separating
medium then cold cure acrylic resin was poured in the molds and before complete setting the
teeth were fixed in the cold cure acrylic resin. Further finishing was done.
 Teeth Preparation and bonding procedures:
Freshly extracted bovine teeth stored in Saline, Labial surfaces of the teeth were initially
prepared by placing depth orientation grooves (0.3 mm) in-depth, and the labial surface was
flattened by a customized paralleling device assembly for preparation standardization. Then
etched with phosphoric acid 37% (gel) for 30 seconds then rinsed with air-water jet for 30
seconds. The bonding agent was applied and activated for 15 seconds then light-cured
according to manufacture instructions.the Ceramic samples were etched by HF acid 9.5% for
20 seconds then rinsed with air and water spray and silinated according to manufacture
instructions.
The teeth are stored in Saline for the preservation of the teeth without any effect on its
grapheme and also removal of any debris. Ceramic discs were bonded on freshly extracted
bovine teeth directly after treatment to mimic the intraoral situation with 50 (N) perpendicular
load using a dental surveyor was placed on the external surface of the veneer after cement
application for 30 seconds and light-activated for 40 seconds LED curing light with an 11-
mm-diameter tip positioned 1.0 mm from the veneer surface.
After the cementation procedure, the specimens were stored in distilled water at 37 °C for 24
h to mimic the intraoral situation.
 Laser debonding:

Water Lase IPLUS Er;Cr:YSGG (Biolase, USA) applied laser beam of wavelength 2780 nm
using the following settings for each group, The turbo handpiece is positioned perpendicular
to the veneer surface at a distance verified by a custom made positioner for standardization of
energy density. except the specimens of subdivision (i) was demolished once subjected to the
shear bond strength test, hence these subdivisions were crucial and mentioned as control
group

Operation Mode Free Running Pulse

Handpiece turbo(MX7)

Repetition rate 20 Hz

Power 4.5 W

Pulse duration (60µs) H mode

Air 60%

Water 80%

Non-Contact mode 5mm away

Table (7): WaterLase parameters for debonding procedures:

 Scanning Electron Microscope Evaluation:

After laser debonding procedures were applied, random samples for each group of ceramic
were taken to examine surface tomography and evaluate atomic composition ( EDAX) using a
scanning electron microscope with magnification 10,000 X and 20,000X. The debonded
ceramic discs was first mounted on aluminum stubs and sputted with a gold layer using
sputter coater and then evaluated.

 Shear Bond Strength:

The fitting surface by inspection was clear enough for rebonding procedures while the
adhesive resin remnant on the tooth surfaces was removed by using a finishing bur to obtain
a standardized flat surface for subsequent rebonding procedures,before testing each specimen
was numbered with a marker for ease of differentiation between groups during breaking then
the samples were mounted onto the machine. They were stabilized to ensure that the 1-mm-
thick edge of the shearing blade was positioned as close as possible to the tooth-ceramic
interface. The shear force was applied at a crosshead speed of 1 mm/min. The shear bond
strength values were recorded in MPa. Universal testing machine (Instron, North America)
was used to investigate the difference between shear bond strength of control irradiated group
and lased groups after rebonding either cemented by light or dual cured resin cement in order
to compare their longevity and success rate.
RESULTS:
Statistical analysis:

Numerical data were explored for normality by checking the distribution of data and using
tests of normality (Kolmogorov-Smirnov and Shapiro-Wilk tests). EDAX data showed non-
normal (non-parametric) distribution while the shear bond strength data showed parametric
distribution. Non-parametric data were presented as median and range values while
parametric data were presented as mean, standard deviation and 95% Confidence Interval for
the mean values. For parametric data; Mann-Whitney U test was used to compare between the
two ceramics. Dunn’s test was used for pair-wise comparisons. For parametric data; Three-
way ANOVA test was used to study the effect of ceramic, curing and rebonding on shear
bond strength. Bonferroni’s post-hoc test was used for pair-wise comparisons when ANOVA
test is significant. The significance level was set at P ≤ 0.05. Statistical analysis was
performed with IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.

Scan Electron Microscope Evaluation:

The SEM images revealed:
 The IPS Emax CAD showed the typical lithium disilicate crystals embedded in a glass
matrix, rod shaped that are interlocked and haphazardly organized (green arrow
indicates remnants of resin cement).
 The VITA MARK II showed a microstructure based on aluminum, potassium and
sodium-based silicate with grains of approximately 4 µm, porous material, described
as honeycombed surface (green arrow indicates remnants of resin cement).

(10,000X) (20,000x)

Figure (1): SEM IPS Emax CAD evaluation at baseline.

 (10,000X) (20,000X)

Figure (2): SEM VITA MARK II evaluation at baseline.

(10,000X) (20,000X)

Figure (3): IPS Emax CAD cemented by Light cure resin cement evaluation after laser
debonding procedures.

(10,000X) (20,000X)

Figure (4): IPS Emax CAD cemented by Dual cure resin cement evaluation after laser
debonding procedures.

(10,000X) (20,000x)
Figure (5): VITA MARK II cemented by Light cure resin cement evaluation after laser
debonding procedures.

(10,000X) (20,000x)

Figure (6): VITA MARK II cemented by Dual cure resin cement evaluation after laser
debonding procedures.

EDAX results (Atomic %)

The scan electron microscope analysis for the atomic percentage of various elements was
performed twice for both materials, once before bonding and was designated as the control
group, and the second time for both VITA MARKII and IPS E.max after the ceramic discs
had been debonded by the Er, Cr: YSGG Laser using the same parameters in all groups. The
results revealed that:

Carbon: there was a statistically significant difference between Carbon atomic % values of
different groups (P-value = 0.023, Effect size = 0.814). Pair-wise comparisons between the
groups revealed that there was no statistically significant difference between IPS E.max
cemented by dual cure resin and VITA MARK II cemented by light cure resin groups; both
showed the statistically significantly highest mean Carbon atomic %. There was no
statistically significant difference between IPS E.max cemented by light cure resin and VITA
MARK II cemented by dual cure resin groups; both showed the statistically significantly
lowest mean Carbon atomic %. Carbon was not found in IPS E.max control and VITA
MARK II control groups.
Oxygen: there was a statistically significant difference between Oxygen atomic % values of
different groups (P-value = 0.007, Effect size = 0.914). Pair-wise comparisons between the
groups revealed that IPS E.max control group showed the statistically significantly highest
mean Oxygen atomic %. There was no statistically significant difference between IPS E.max
cemented by light cure resin and VITA MARK II control groups; both showed statistically
significantly lower mean Oxygen atomic %. IPS E.max cemented by dual cure resin showed
statistically significantly lower mean value. There was no statistically significant difference
between VITA MARK II cemented by light cure resin and VITA MARK II cemented by dual
cure resin groups; both showed the statistically significantly lowest mean Oxygen atomic %.
Aluminum: there was a statistically significant difference between Aluminum atomic %
values of different groups (P-value = 0.007, Effect size = 0.927). Pair-wise comparisons
between the groups revealed that VITA MARK II control showed the statistically
significantly highest mean Aluminum atomic %. VITA MARK II cemented by dual cure resin
group showed statistically significantly lower mean value followed by VITA MARK II
cemented by light cure resin group. There was no statistically significant difference between
IPS E.max control group and IPS E.max cemented by light cure resin groups; both showed
statistically significantly lower mean Aluminum atomic %. IPS E.max cemented by dual cure
resin showed the statistically significantly lowest mean Aluminum atomic %.
Silica: there was a statistically significant difference between Silica atomic % values of
different groups (P-value = 0.007, Effect size = 0.901). Pair-wise comparisons between the
groups revealed that IPS E.max control group showed the statistically significantly highest
mean Silica atomic %. There was no statistically significant difference between IPS E.max
cemented by light cure resin, IPS E.max cemented by dual cure resin and VITA MARK II
control groups; all showed statistically significantly lower mean Silica atomic %. There was
no statistically significant difference between VITA MARK II cemented by light cure resin
and VITA MARK II cemented by dual cure resin; both showed the statistically significantly
lowest mean Silica atomic %.
Phosphorus: there was a statistically significant difference between Phosphorus atomic %
values of different groups (P-value = 0.016, Effect size =0.821). Pair-wise comparisons
between the groups revealed that there was no statistically significant difference between IPS
E.max control group and IPS E.max cemented by light cure resin groups; both showed the
statistically significantly highest mean Phosphorus atomic %. IPS E.max cemented by dual
cure resin showed statistically significantly lower mean value. There was no statistically
significant difference between VITA MARK II cemented by light cure resin and VITA
MARK II cemented by dual cure resin group; both showed the statistically significantly
lowest mean Phosphorus atomic %. Phosphorus was not found in VITA MARK II control
group.
Fluoride: there was a statistically significant difference between Fluoride atomic % values of
different groups (P-value = 0.016, Effect size = 0.923). Pair-wise comparisons between the
groups revealed that VITA MARK II control group showed the statistically significantly
highest mean Fluoride atomic %. There was no statistically significant difference between
VITA MARK II cemented by light cure resin and VITA MARK II cemented by dual cure
resin groups; both showed statistically significantly lower mean Fluoride atomic %. IPS
E.max cemented by dual cure resin group showed the statistically significantly lowest
Fluoride atomic %. Fluoride was not found in IPS E.max control and IPS E.max cemented by
light cure resin groups.
Sodium: there was a statistically significant difference between Sodium atomic % values of
different groups (P-value = 0.009, Effect size = 0.950). Pair-wise comparisons between the
groups revealed that VITA MARK II control groups showed the statistically significantly
highest mean Sodium atomic %. There was no statistically significant difference between
VITA MARK II cemented by light cure resin and VITA MARK II cemented by dual cure
resin groups; both showed statistically significantly lower mean Sodium atomic %. There was
no statistically significant difference between IPS E.max cemented by light cure resin group
and IPS E.max cemented by dual cure resin groups; both showed the statistically significantly
lowest mean Sodium atomic %. Sodium was not found in IPS E.max control group.
Potassium: there was a statistically significant difference between Potassium atomic %
values of different groups (P-value = 0.009, Effect size = 0.950). Pair-wise comparisons
between the groups revealed that VITA MARK II control groups showed the statistically
significantly highest mean Potassium atomic %. There was no statistically significant
difference between VITA MARK II cemented by light cure resin and VITA MARK II
cemented by dual cure resin groups; both showed statistically significantly lower mean
Potassium atomic %. There was no statistically significant difference between IPS E.max
cemented by light cure resin and IPS E.max cemented by dual cure resin groups ; both
showed the statistically significantly lowest mean Potassium atomic %. Potassium was not
found in IPS E.max control group.
Calcium: there was a statistically significant difference between Calcium atomic % values of
different groups (P-value = 0.020, Effect size = 0.855). Pair-wise comparisons between the
groups revealed that IPS E.max cemented by dual cure resin group showed the statistically
significantly highest mean Calcium atomic %. VITA MARK II control group showed
statistically significantly lower Calcium atomic %. There was no statistically significant
difference between IPS E.max cemented by light cure resin and VITA MARK II cemented by
light cure resin groups; both showed the statistically significantly lowest Calcium atomic %.
Calcium was not found in IPS E.max control and VITA MARK II cemented by dual cure
resin groups.
Table (11): The mean, standard deviation (SD) values and results of Kruskal-Wallis test for
comparison between atomic weight % of different elements in the different
groups.

e.max e.max e.max VITA VITA VITA

Control Light Dual Control Light Dual Effect
P- size
Element
value (Eta
Mean Mean Mean Mean Mean Mean squared)
(SD) (SD) (SD) (SD) (SD) (SD)

Carbon 28.7 34.4 37.6 31.9

- - 0.023* 0.814
(2.2)B (1.9)A (1.2)A (1.3)B

Oxygen 64.6 0.6 43.3 49 33.3 37.1

0.007* 0.914
(2.6)A (0.1)B (1.8)C (2)B (1.9)D (2.5)D

Aluminum 2.1 0.6 2.1 7.2 2.9 4

0.007* 0.927
(0.1)D (0.1)E (0.1)D (0.2)A (0.5)C (0.1)B

Silica 30.8 15.8 13.9 18.1 10.3 12.7

0.007* 0.901
(2.3)A (1.5)B (1.1)B (1.4)B (0.3)C (1.1)C

Phosphorus 2.6 2.8 1.5 0.7 0.7

- 0.016* 0.821
(2.3)A (0.2)A (0.1)B (0.1)C (0.2)C

Fluoride 2.2 12.6 8.8 7.8

- - 0.016* 0.923
(0.1)C (0.7)A (0.1)B (0.2)B

Sodium 0.8 0.4 7.3 3.9 4.4

- 0.009* 0.950
(0.1)C (0.1)C (0.6)A (0.1)B (0.2)B

Potassium 0.8 0.5 3.5 2 2.4

- 0.009* 0.950
(0.1)C (0.1)C (0.1)A (0.2)B (0.1)B

Calcium 0.3 1 0.7 0.2

- - 0.020* 0.855
(0.1)C (0.04)A (0.1)B (0.02)C

*: Significant at P ≤ 0.05, Different superscripts in the same row indicate statistically significant difference
between groups
Figure (35): Bar chart representing mean and standard deviation
.elements in the studied groups

80
70
60
50
Atomic %

40
30
20
10
0
Carbon Oxygen Aluminum Silica Phosphorus Fluoride Sodium Potassium Calcium
Element
e.max Control e.max Light e.max Dual VITA Control VITA Light VITA Dual
:Shear bond strength
Three-way ANOVA results: showed that ceramic (regardless of curing and rebonding) had a
statistically significant effect on mean shear bond strength. Curing (regardless of ceramic and
rebonding) had a statistically significant effect on mean shear bond strength. Rebonding
(regardless of ceramic and curing) had a statistically significant effect on mean shear bond
strength. The interaction between the three variables also had a statistically significant effect
on mean shear bond strength. Since the interaction between the variables is statistically
significant, so the variables are dependent upon each other.

Effect of different interactions on shear bond strength

1. Comparison between ceramics:

Regarding control group whether with light or dual cure modes; e.max showed statistically
significantly lower mean shear bond strength than VITA (P-value <0.001, Effect size = 0.788)
and (P-value <0.001, Effect size = 0.935), respectively.
After rebonding and using light cure mode; there was no statistically significant difference
between mean shear bond strength of the two ceramics (P-value = 0.065, Effect size = 0.102).
After rebonding and using dual cure mode; e.max showed statistically significantly lower
mean shear bond strength than VITA (P-value <0.001, Effect size = 0.939).

2. Comparison between curing modes:

Regarding control whether with e.max or VITA; light curing mode showed statistically
significantly lower mean shear bond strength than dual curing (P-value <0.001, Effect size =
0.629) and (P-value = 0.003, Effect size = 0.242), respectively.
After rebonding whether with e.max or VITA; light curing mode showed statistically
significantly lower mean shear bond strength than dual curing (P-value <0.001, Effect size =
0.541) and (P-value = 0.003, Effect size = 0.966), respectively.

3. Effect of rebonding:

Regarding e.max with light curing mode; there was no statistically significant difference
between mean shear bond strength of control and rebonding (P-value = 0.598, Effect size =
0.009). While with dual curing mode; rebonding showed statistically significantly higher
mean shear bond strength than control (P-value <0.001, Effect size = 0.840).
While for VITA with light curing mode; rebonding showed statistically significantly lower
mean shear bond strength than control (P-value <0.001, Effect size = 0.848). As regards
VITA with dual curing mode; rebonding showed statistically significantly higher mean shear
bond strength than control (P-value <0.001, Effect size = 0.853).
Table (8): The mean, standard deviation (SD) values and results of three-way ANOVA test
for comparison between shear bond strength values with different interactions of variables.

e.max VITA Effect size

P-value
(Partial
Rebonding Curing (effect of
eta
Mean SD Mean SD ceramic)
squared)

LC resin 91.3 11.3 186.2 15.1 <0.001* 0.788

DC resin 27.2 6.1 214 16.7 <0.001* 0.935

Control P-value (curing

mode) <0.001* 0.003*

Effect size (Partial

0.629 0.242
eta squared)

LC resin 86.7 11 70.1 12.7 0.065 0.102

DC resin 140.1 16 332.5 17.5 <0.001* 0.939

Rebonding P-value (Effect of

curing) <0.001* <0.001*

Effect size (Partial

eta squared) 0.541 0.966

P-value LC resin 0.598 <0.001*

(Effect of
rebonding) DC resin
<0.001* 0.848

Effect size LC resin 0.009 <0.001*

(Partial eta
squared) DC resin
0.840 0.853

*: Significant at P ≤ 0.05
 004

053

003

052

002
xam.e
051 ATIV
001
)aPM( htgnerts dnob raehS

05

0
gniruc-thgiL gniruc-lauD gniruc-thgiL gniruc-lauD
lortnoC gnidnobeR

Figure (39): Bar chart representing mean and standard deviation values for shear bond
strength with different interactions of variables.
DISCUSSION:
Porcelain veneer restorations were introduced in the early 1980s as a conservative and reliable
esthetic restoration expressing excellent clinical performance so they became one of the most
predictable, most aesthetic, and least invasive modalities of treatment[8]. Literature has
demonstrated the presence of different all-ceramic materials and systems, Among the introduced
ceramic materials is glass based feldspathic ceramics and lithium disilicate, they offers excellent
optical effects by imitating the natural enamel and dentin features, good esthetics and mechanical
properties. The material can be applied in many clinical situations such as inlays, onlays, veneers
and crowns[8].
The desire for more durable aesthetic outcomes did not confine to improve the material type only
but also the bonding protocol including the luting cement. Usually these kinds of restorations are
adhesively cemented, its bonding to tooth structure is considered efficiently strong as it depends
on micromechanical adhesion[9].However, the recent advances in materials and technology,
failure is still persist. Several factors can result in ceramic restoration failure; many of these
failures are related to the restoration fabrication, others related to bonding procedures or
practitioner experience .thus failures are liable to occurs during function and would thereby lead
to remake purpose[10].
Although the feldspathic and lithium disilicate restorations offer excellent optical effects by
imitating the natural enamel and dentin features, the removal procedure is challenging due to the
high bond strength, which is provided by using resin luting cements[11], also the removal
procedures is considered a challenging and time-consuming process and the conventional
technique still risk the underlying tooth structure due to the lack of color contrast between tooth,
adhesive resin interface and the restoration[12].
Recently, laser technology was introduced as a more comfortable and conservative technique for
ceramic veneer removal, one of its advantages is to overcome the limitations of the conventional
technique as it depends on the thermal effect of the laser in softening the luting adhesive resin
based on the absorption of water-rich substances like monomers[2]. However, limited data is
available on the bond strength of rebonded all-ceramic restorations on enamel and dentin
surfaces. The main purpose of this study was to evaluate the efficiency of Er,Cr:YSGG laser in
debonding of all-ceramic veneers and to investigate the bond strength changes of the rebonded
ones, which were removed after Er,Cr:YSGG laser application.
In this vitro study, lithium disilicate (IPS E.max) and feldspathic porcelain (Vita Mark II) were
selected, since both materials offer satisfactory level of esthetics and mechanical properties,
owing to unique microstructure. The IPS E.max composed of glass matrix infiltrated by micron-
size crystals of lithium disilicate, creating a highly filled glass matrix, while the vita mark II
consists of fluorapatite crystals in an aluminum-silicate glass .Both were demonstrated as
CAD/CAM blocks to standardize manufacture technique and defects[5].
Specimens were sectioned from LT A1 CAD/CAM blocks using Isomet. The width and height of
the specimens were 10mm× 10mm, according to block size (C14 & I14). 0.7mm specimen
thickness was standardized for all groups (n=10) as it was recommended as the thickness needed
for an all ceramic veneer[2, 13].

19
In this study Freshly extracted bovine teeth were used owing to its hardness and we can apply on
it the Er,Cr:YSGG laser at the stage of laminate veneers debonding and its considered as
substitute for human teeth in dental research[14, 15]. The ceramic discs were cemented using
resin cements; light cure resin cement(Relay x veneer )in one group due to their high esthetics,
low solubility, high bond strength, and superior mechanical properties that help reinforce the
ceramic restorations[16, 17], and for representing different curing modes the other group was
cemented using dual cure resin cement (Relay x ultimate clicker)[18, 19].
As reported in previous studies [20-22], using erbium lasers is a suitable alternative to
conventional all ceramic removal techniques. Effective laser parameters should be selected
according to the target properties: the type of bonded tooth surface, the ceramic type, and the
thickness of the restoration.Zhang et al.[23] used an Er:YAG laser with 4/4 air-water cooling, at
100 mJ energy and 30 Hz frequency to investigate the debonding time. In a study by Gurney et
al.[24] , the Er:YAG laser was used with 3.5 W and 4 W of powers, 60% air and 30% water
cooling, 25 Hz pulse rate for debonding with a laser conservatively for teeth and veneers.
Morford et al. [25] tested different Er:YAG laser parameters: 133, 217, 316, 400, and 503 mJ
energies, with a pulse repetition rate of 10 Hz for veneer debonding. Oztoprak et al. [13]selected
a laser parameter at a power of 5 W (50 Hz × 100 mJ) to evaluate the shear bond strength values
after different application durations.
The laser beam that was applied of wavelength 2780nm using the following settings for each
group Power: 4.5 W, Repetition rate: 20 Hz, Pulse duration (60µs) H mode, Air: 60%, Water:
80% and Non-Contact mode 5mm away Hand piece: turbo (MX7 fiber tip with a spot diameter
of 700 µm in focus distance) compared with the 50 Hz and 100 mJ used by Oztoprak et al[21].
It was mentioned that the distance of the laser’s head from the surface can affect the quality of
lasers. In parallel with the study of Al-balkhi et al. [2]who studied the efficiency of Er:YAG laser
in debonding of porcelain laminate veneers by contact and non-contact laser application modes,
as recommended the distance was set at 3-5 mm[2]. The laser application was made by scanning
method, perpendicular to the disc surface with circular movements, in clockwise direction, from
outer circle to the center of the cemented disc specimen, the procedure was repeated until the
strokes under the veneer sound and feel differently[18], so it was of interest to test the turbo
handpiece significance in debonding porcelain laminate veneers.
Morford et al., stated that future scanning electron microscopical investigations, which will
provide better detailed information about the surface of the enamel and even more importantly
about the veneer surface after laser debonding will be necessary to assess possible changes or
damage of the veneer due to the ablation process[25].Therefore, the laser debonding technique,
which reduces the required forces to prevent the risk of tooth and ceramic damage, was
examined in the present study by SEM images 10,000x and 20,000x magnifications.
Zheng et al., mentioned that EDX can be used to confirm the composition and distribution of the
nanoparticles through spectrum and elemental mapping[26]. Toning to Morford
recommendations compositional identification of nanoparticles using an EDX spectrometer
incorporated into a scanning electron microscopy (SEM) system was done twice at baseline and
after debonding of ceramic discs specimens using laser.
Rebonding of a failed or removed restoration to previously bonded enamel and/or dentin may be
compulsory in the prosthodontics practice of resin-luted restorations like all-ceramic crowns and
laminate veneers. However, limited data about how the bond strength is affected after the

20
rebonding process, and no data about how laser debonding affects the bond strength of a
rebonded ceramic restoration are available[18]. So evaluating the shear bond strength was
beneficial in our study.

The results of the current study revealed that:

Scan electron microscope showed no damage or signs of ablation or ablation craters on the
porcelain laminate veneers were detected. In parallel with the study of Morford et al., he
mentioned the incident light microscopic pictures revealed that the bond between veneer and
tooth enamel is disrupted mainly at the veneer cement interface therefore leaving the majority of
the veneer clean also this observation emphasizes that laser ablation rather than thermal
softening of the cement achieves debonding of veneers[25]. Keeping in consideration the mode
of action of mentioned wavelength mainly operates by absorption of the laser energy in the
water.
And for EDAX analysis; first at the base line shows results very similar to those described by the
manufacturer. Then the second time analysis done after laser irradiation with these parameters
for debonding in general showed differences in the chemical composition compared with
baseline groups and even variations by changing the cement curing mode were detected.
We can attribute this to the organic contamination of the surface during the multi-step
preparation of the ceramic layers, some elements were already present but with difference in the
atomic percentages while others newly appeared,The differences of elemental percentages may
be explained by the structure of the ceramic, which is not homogeneous, thus resulting in
structural variations of the tested zones.
The elements newly appeared can be explained by residuals on the micro porosities created by
HF acid used before cementation, This result agrees with study of steinhauser et al[27] stated
following etching of silica-based ceramics, it has been observed that hydrofluoric acid leads to
the formation of insoluble byproducts, such as silica and fluoride salt, which may remain on
ceramic surface[27]. Finally, we can state that EDAX is considered as semi- quantitative tool
that mainly helps us to monitor the elemental determination regardless its atomic percentage.
Rebonding of a failed or removed restoration to previously bonded enamel and/or dentin may be
compulsory in the prosthodontic practice of resin-luted restorations like all-ceramic crowns and
laminate veneers [11]. However, limited data about how the bond strength is affected after the
rebonding process, and no data about how laser debonding affects the bond strength of a
rebonded ceramic restoration are available. Contradictory findings exist in the published
literatures concerning the effects of repeated bonding on the shear bond strength of ceramic
brackets. Some demonstrated that the strength decreased considerably after the second bonding
[28], whereas others reported the same values as the initial bond strength[29], Bulut et al. [30]
reported that there was no significant difference among the initial bonding strength and the first
and second rebonding strengths on enamel, or between the initial bonding strength and first
rebonding strength on dentin
The shear bond streanght in the present study, comparing non lased ceramic discs groups, IPS
Emax showed lower bond strength than VITA MARK II. the bond strength is also affected by
the curing mode of adhesive were light curing mode showed lower shear bond strength than dual

21
curing mode advocated by Mowafy et al., as he mentioned that the dual-cure resin cements were
developed to ensure the polymerization which curing light can’t reach[31].
Hofmann et al., also mentioned the degree of conversion in polymerization reaction depends on
the energy supplied during light polymerization, characterized by the product of light intensity
and exposure time[19].Bulut et al., reported that there was no significant difference among the
initial bonding strength and the first and second rebonding strengths on enamel, or between the
initial bonding strength and first rebonding strength on dentin[30].
However the results of Karagoz et al., study were not in agreement with the results of the present
study in which the control and rebonding groups exhibited high bond strength to tooth surfaces,
and the majority of failures in the control and the rebonding groups were adhesive failures that
occurred between the luting resin cement and the tooth surface so the removal of all-ceramic
restorations by using the Er:YAG laser did not affect the rebonding strength values[18].
In present study the bond strength of IPS Emax recemented using light curing resin shows no
change from control group while group recemented using dual cured resin showed higher mean
shear bond strength than control group.
VITA MARK II ceramic discs rebonded using light cured resin showed lower mean shear bond
strength than control, regarding VITA MARK II recemented using dual cured resin showed
higher mean shear bond strength than control.
As a conclusion the interaction between the three variables (ceramic type, curing mode,
rebonding after laser irradiation) had a significant effect on mean shear bond strength.
Ramakrishnaiah et al., mentioned Effect of Hydrofluoric Acid Etching Duration on the Surface
Micromorphology, Roughness, and Wettability of Dental Ceramics so this result can be
explained by residuals of HF acid in micro porosities and the polymerization of the resin
cement[32] .

22
CONCLUSION:

From the light of this in vitro study based on the results the following conclusions could be
drawn:

 Er,Cr:YSGG hydrokinetic laser system used for debonding a resin-bonded all-ceramic

restoration is an effective clinical application. It can be said that the application of a laser
for debonding ceramic restorations could serve as a practical and effective debonding
method that eliminates the risk of restoration fractures.
 The laser irradiation had no effect on either IPS E.max or Vita MARK II
 The presence of cement remnants after debonding demonstrated the thermal and ablative
effects induced by irradiations only in the cement layer, implying that the protocols used
may be suitable for future clinical application.
 The curing mode of resin cement have no effect on debonding efficiency of transmitted
laser of wavelengths in the Erbium Family of Dental Lasers (using turbo hand piece).

23
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