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OPERATIVE DENTISTRY 2 | DOD2 41

Indirect Tooth Colored Restorations

Ture Dr Kathrene Faye Lampa
First Semester – Midterms
Topics  Because of brittleness
 Indirect Tooth-colored Restorations
• Laboratory-processed composite
• Feldspathic porcelain
• Hot-pressed glass ceramics Indications
 Cases requiring excellent esthetics regardless of cost and number of
• Lithium Disilicate — pressed and machinable
appointments
• CAD-CAM Restorations
 Inlays
Direct Composite Restorations
 Onlays

 Crowns

 Short span bridges (lab-processed composite material requires

fiber reinforcement)

 Large defects or previous restorations

• Open proximal contacts • Because of polymerization shrinkage

• Poor Anatomy that happens in direct composite usually Contraindications
•Monochromatic and lacks translucency recurrent caries occur
 Heavy occlusal forces

 Inability to maintain a dry field

Advantages of Indirect Tooth-colored Restorations  Deep subgingival preparations
 Improved physical properties (free of voids and matrix maximally
polymerized-under pressure, vacuum, inert gas, intense light, heat or a
combination of these conditions)
INDIRECT COMPOSITE RESTORATION
 Greater resistance to wear:
(A.K.A. LABORATORY-PROCESSED COMPOSITE, POLYMER GLASSES, FILLED
 Ceramics > Lab processed Co > Direct Co
POLYMERS, CERAMICS OPTIMIZED RESINS OR CEROMERS)
 Variety of materials and techniques

 Improved wear resistance

Cavity Design
 Reduced polymerization shrinkage  You must know what material you will use first before starting the
cavity preparation
 Ability to strengthen tooth structure
 Preparations are meant to provide adequate thickness for the
 More precise control of contours and contacts restorative material and at the same time a passive insertion pattern
with rounded internal angles and well-defined margins .
 Biocompatibility and good tissue response

 Increased auxiliary support

Tooth Preparation Features
 90° (butt-joint) cavosurface margins
Disadvantages of Indirect Tooth-colored Restorations  Rounded internal and external line and point angles
 Increased cost and time
 Divergent walls (2° - 5°) - path of insertion
 Technique sensitive
 1.5 — 2 mm pulpal depth & cusp reduction - provide space for the
 Difficult try-in and delivery
materials
 Brittleness of ceramics
 Isthmus width and groove extensions are at least 1.5 mm
 Wear of opposing dentition and restorations
 Walls of proximal box are 0.5 mm out of contact
 Low potential for repair (?)

 Can actually repair the ceramic material with composite

 Need to know the technique and material

 In the case of ceramics, can abrade opposing teeth

 Short clinical track record

No cusp involed ,1.5 mm isthmus

Laboratory-Processed Composites
 More resistant to wear compared to direct composites

Cusp involved

**Partial crown, shorter bur (resto) long bur (prostho)

Inlay Tooth preparation

Pre-op picture of failing amalgam Finished cavity preparations

and composite restorations

**Acknowledgement: Pictures are from Processed Composite Resin for

Esthetic Reconstruction by Dr. Ross Nash. Contemporary Esthetics and
Restorative Practice March 2002, pp 72-76

Indirect or Laboratory Processed Posterior Composite Restoration

Gingival retraction and hemostasis Margins dry and clear, ready for
using Expasil™ (rubber based impression taking
retraction materials)

Onlay Tooth preparation

  Excellent proximal contours and contacts. Also, no cervical overhangs

Bisacrylic (Temphase®, Ken- Corp.) Provisionals cemented with non-

temporary restorations eugenol temporary cement
(TempBond® NE, Kerr Corp.)

Picture taken from: Scientific Based Rationale and Protocol for use of Modern
Indirect resin Inlay and Onlay, J Blank, JEsthet Dent, 2000

Processed composite restorations Restorations with excellent

on the dies. anatomical contours and surface
finish

Picture taken from: Scientific Based Rationale and Protocol for use of Modern
Indirect resin Inlay and Onlay, J Blank, J Esthet Dent, 2000

Internal surfaces of the restorations Rubber dam isolation

sandblasted and coated with silane
material

Picture taken from: Scientific Based Rationale and Protocol for use of Modern
Indirect resin Inlay and Onlay, J Blank, JEsthet Dent, 2000

Application of adhesive resin on Cementation using dual cured resin

moist cavity after 37% phosphoric cement, Nexus™ 2
acid etching
Picture taken from: Scientific Based Rationale and Protocol for use of Modern
Indirect resin Inlay and Onlay, J Blank, J Esthet Dent, 2000
Materials for Temporary Restorations

Picture taken from: Conservative Treatment Planning in the Posterior

Quadrant by Gary Radzz PPAD, 2004

Picture taken from: Conservative Treatment Planning in the Posterior

Quadrant by Gary Radz, PPAD, 2004

Picture taken from: Scientific Based Rationale and Protocol for use of Modern
Indirect resin Inlay and Onlay, J Blank, J Esthet Dent, 2000

Picture taken from: Conservative Treatment Planning in the Posterior

Quadrant by Gary Radzz PPADZ 2004

Picture taken from: Scientific Based Rationale and Protocol for use of Modern Resin Cements
Indirect resin Inlay and Onlay, J Blank, JEsthet Dent, 2000

Rely-X Resin Cement (3M ESPE) Panavia F 2.0 (Kuraray Dental Corp)

Pictures taken from: Conservative Treatment Planning in the Posterior

Quadrant by Gary Radz, PPAD, 2004
Picture taken from: Conservative Treatment Planning in the Posterior
Quadrant by Gary Radz, PPAD, 2004

Picture taken from: Conservative Treatment Planning in the Posterior

Quadrant by Gary Radz, PPAD, 2004

Steps in Processing Laboratory-Processed Composites

(Old School Method)
1. Impression

2. Die Fabrication

3. Build-up with composite

4. Light cure for 1 minute on each surface

5. Final cure in oven: heat and light for 7 mins, or boil for 10 mins

6. Remove inlay from the die, cool, trim and polish

Types of Ceramic Inlays and Onlays

Case #1: Lab-processed Composite
 (1) Feldspathic porcelain  1. Tooth prep

 Jacket crown  2. Impression taking

 Relatively inexpensive  3. Pouring of master cast, send to lab

 Technique sensitive  4. Duplication of cast and pouring of refractory die (rd)

 Considered weak and incidence of fracture is high  5. Porcelain is built up incrementally on the die and fired

 Because of processing technique of porcelain  6. Porcelain restoration is seated on the master cast for
adjustment and finishing

 (2) Pressed Glass-Ceramics (aka Hot pressed glass ceramics)

 Brand names like Dicor and IPS Empress

 Restoration made using the lost wax technique

 Excellent marginal fit

 Moderately high strength

 Surface hardness similar to enamel

 (3) Lithium Disilicate (IPS e.max press, IPS e.max CAD)

 Moderately high-strength glass ceramics

 Relatively new so long-term clinical studies are lacking

(2) Hot-Pressed/Castable Ceramics

 Dicor was patented in 1984
 (4) CAD-CAM (Cerec 3D of Sirona Dental Systems and E4D of D4D
Technologiues  Translucent so needs external shading

 Uses lost-wax, centrifugal casting

Tooth Preparation Features  Empress

 90° (butt-joint) cavosurface margins
 Uses lost-wax process but pneumatically pressed into mold
 Rounded internal and external line and point angles
 Stronger than porcelain inlays
 Divergent walls (2° ’ 5°)

 1.5 — 2 mm pulpal depth & cusp reduction

 Isthmus width and groove extensions is at least 1.5 mm

 0.5 mm out of contact

(1) Feldspathic Porcelain

 Dental porcelains that are partially crystalline minerals (feldspar, silica,
alumina) dispersed in a glass matrix.'

 Porcelain restorations are made from finely ground ceramic powders

that are mixed with distilled water or a special liquid, shaped into the
desired form, then fired and fused together to form a translucent,
material that looks like tooth structure.

Feldspathic Porcelain Inlays/Onlays Hot-pressed Ceramic Inlays/Onlays

 Procedure  Procedure
 1. Tooth prep Machinable Ceramics
 2. Impression taking  Common use Lithium Disilicate

 3. Pouring of master cast, send to lab  Use CAD/CAM systems

 4. Wax pattern making, spruing, investing & burn-out  Done chairside in 1 appointment - if there is a machine

 5. Melting of ceramic ingot (1100° C), and pressed into mould  Use high-quality ceramic blocks: optimized physical properties
using pneumatic or centrifugal force
 High cost & needs training
 6. Cool and recover from the mold

 7. Ceramming at 1070 deg Celscius for 6 hours

 8. Porcelain restoration is seated on the master cast for

adjustment and finishing

 9. Application of pigments or stains

CAD-CAM Milling

 CEREC (Sirona)

 SOPHA System (Bioconcept Inc.)

 DentiCAD System (Digital Dental Systems & BEGO

 CICERO (Elephant, Holland)

 ProCera (Nobelpharma)

Copy Milling (CAM)

 CELAY (Mikrona Technologie AG)

Steps in Processing Machinable Glass Ceramic

1. Cavity prep, then take an optical impression

2. Input in the computer (CAD) to confirm the boundaries of the

restoration

3. Activate the CAM to mill the inlay out of ceramic

4. Try-in

5. Adjust according to the occlusal anatomy

6. Etch the cavity side of the inlay with Aluminum bifluoride, silanating
agent

7. Etch the tooth with phosphoric acid, bond

8. Cement with resin cement, cure

9. Polish

 “The name CEREC stands for CEramic REConstruction. The method

was developed by Prof. Werner Mormann and Dr. Martin Brandestini
(3) Machined Restorations in 1980 at the University of Zurich in Switzerland. The first patients had
(CAD-CAM Milling and Copy Milling) been treated with CEREC inlays in 1985 at the University of Zurich.
From this time CEREC has undergone continuous technical and clinical
 developments. Today it is used worldwide by a growing number of
dentists in their practices”.

Procedure
3M Ceramic Blocks Pre-op picture of failing composite
C hairside • Excellent fracture and wear restoration on 16
E conomics resistance
R estorations • Pore-free
E sthetic
C eramics

 “The CEREC method combines adhesive bonding techniques with rapid

production of all-ceramic inlays, onlays, partial crowns, veneers and
crowns for the anterior, premolar and molar regions. This results in a
unique combination creating biocompatible, non-metallic, natural
looking restorations from durable high-quality ceramic materials, in a
single treatment session, and without the need of provisional fillings”.

CEREC 3 (Sirona) CEREC 3, Acquisition Unit

Full arch picture Finished cavity preparation
• Butt-joint margins
• No need to prepare diverging
walls

Milling Unit and Acquisition Unit

Rubber dam isolation Application of white powder on

cavity preparation
CEREC 3, Acquisition Unit

Milling Unit Finished Crown

Appearance of a uniformly coated
tooth that is ready for optical
impression taking
Try-in of milled restoration. Note the
inadequate milling of the occlusal
anatomy.
Acid etching of enamel and dentin
Cementation of restoration that had
been hydrofluoric acid etched and
primed with silane material.
Ceramic block in position inside Removal of excess cemend and Finished one-appointment CAD-CAM
milling unit. The machine asks for improvement of occlusal anatomy. restoration, anatomy.
the block with the correct size
depending on the size of the
restoration.
Cleaning of cavity preparation with
air abrasion unit before bonding
procedures
Application of primer/adhesive
resin.
Light curing of filled resin cement.
This cement is usually dual curing -
light and chemical curing.
 Surface Treatment
Material Surface Treatment

Felspathic (Duceram, Degussa 9.5% HF acid for 2-2.5 min, wash,

silane application

Leucite reinforced (IPS Empress I,

Ivoclar, Vivadent)
9.5% HF acid for 60 secs, wash,
Lithium disilicate reinforced (IPS silane application
Empress II, Ivoclar, Vivadent)

Glass infiltrated Aluminum Oxide

(In-ceram Alumina, Vident)

Zirconium-reinforced Al- oxide

ceramic (e.g., In-Ceram Zirconium, Sandblasting with 50 um Al-Oxide,
Vident) wash, silane application

Densely sintered, Al-oxide ceramic

(e.g., Procera AllCeram, Nobel
Biocare)

Laboratory-processed composite Sandblasting with 50 um Al-Oxide,

(e.g., Sinfony (3M), Ceramage wash, silane application
(Shofu), belleGlass (KerrLab)