Ceramics and Adhesives English Anderson

Ceramics and Adhesives: PP-22
CDR Michael R. Andersen, DDS, MS, FACP

23JUNE2022
MICHAEL.R.ANDERSEN.MIL@MAIL.MIL
Disclaimer
Full disclosure; no financial incentives

Any views or opinions in this presentation are solely of those of the
presenter and do not necessarily represent those of the United States Navy
or other branches of the Department of Defense.
Outline of Objectives
Classifications of Ceramics
Material Properties of Ceramics
Ceramic Restorative Material Choices
Bonding to Enamel and Dentin
Bonding to Restorative Materials
My general restorative “go-to’s”:
Resin Cement: Panavia V5
Anterior teeth:
E.max CAD/Press MT or PFZ
Posterior teeth:
Inlays: Direct Composite Vs. Amalgam
Onlays: E.max CAD/Press MT, 3Y or 5Y Zr, or Gold
Crownlays: E.max CAD MT
Crowns: E.max CAD/Press MT, 3Y or 5Y Zr, or Gold
Ceramic
What is a Dental Ceramic?
• “An inorganic compound with nonmetallic properties

typically consisting of oxygen and one or more metallic
or semimetallic elements that is formulated to
produce the whole or part of a ceramic-based dental
prosthesis.”
Anusavice, K., (2003)

Ceramics History in a
Nutshell
• 1889 - Introduction of all-ceramic crowns (Charles Land)
• 1950’s - Porcelain fused to metal crown
• 1971 - First CAD-CAM system for dentistry (Dr. Duret)
• 1983 - CEREC 1 (Drs. Mörmann and Brandestini) - (Siemens, now Sirona)
• 1984 - Dicor - first commercial glass-ceramic for dentistry (Dentsply International)
• 1990 - IPS Empress (Ivoclar-Vivadent)
• 1991 - Vitablocs Mark II (feldspathic blocks) - (Vident)
• 1998 - ProCAD blocks (first leucite reinforced blocks) evolved into Empress CAD (Ivoclar)
• 1998 - IPS Empress 2 (Ivoclar-Vivadent))
• 2000 - Paradigm MZ100 blocks - (3M ESPE)
• 2005 - IPS e.max Press (Ivoclar-Vivadent)
• 2006 - IPS e.max CAD (Ivoclar-Vivadent)
• 2007 - CEREC blocs (Dentsply-Sirona)
• 2010 (June) - Obsidian blocks (Glidewell)
• 2011 (January) - Lava Ultimate (3M ESPE)
• 2012 (December) - Vita Enamic (VITA North America)
• 2013 (September) - HC Block (Shofu)
• 2014 (March) - Cerasmart (now MAZIC Duro?) (GC America)
• 2014 (March ) - TRINIA (Shofu)
• 2016 (February) - Celtra Duo (Dentsply-Sirona)
• 2016 (May) - Vita Suprinity
• 2016 (June)- LiSi Press (GC America)
• 2016 (August)- Celtra Press (Dentsply-Sirona)
Classification Systems
1. Use\indication
2. Composition
3. Processing method
4. Firing temperature
5. Microstructure
6. Translucency
7. Fracture resistance
8. Abrasiveness
Classifications based on microstructure
Kelly, J. R. (2008). Dental ceramics: what is this stuff anyway? Journal of the American Dental Association (1939), 139
Suppl(suppl 4), 4S–7S. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18768902
Gracis S, Thompson VP, Ferencz JL, Silva N, Bonfante EA. (2015) A New Classification
System for All-Ceramic and Ceramic-like Restorative Materials. International Journal of
Prosthodontics. 28:227-235.
A. Glass-based Systems
Mainly silica and various
amounts of alumina
Feldspars
Low mechanical properties
Veneer materials
B. Glass-based systems with Crystalline
Second Phase, Porcelain
Glassy matrix
Varying amounts of crystal

types either added or grown
in the matrix
Leucite
Fluorapatite
Leucite
Lithium Disilicate
Lithium Disilicate
B1. Low-to Moderate Leucite-Containing
Feldspathic Glass
Main use as veneering for
MCR’s
Leucite
potassium and aluminum

tectosilicate
10-20 microns
alters coefficient of thermal

expansion (CTE)
inhibits crack propagation

B2. High-leucite (~50%) Containing Glass,
Glass-Ceramics
Start of as homogenous
glass
2nd heat treatment nucleates

and grows crystals
Improved mechanical and

physical properties
Dispersion strengthening
B3. Lithium Disilicate Glass-
Ceramics
Glass matrix consists of
lithium silicate
~70% lithium disilicate by

volume
Grain size ~0.2-1.0 microns

(CAD) and ~3-6 microns
(Press)
C. Crystalline-based systems with glass
fillers
Interpenetrating phase
composites
Mainly alumina
Introduced in 1988
In-Ceram family
Spinell - 350MPa
Alumina - 450MPa
Zirconia - 650MPa
D. Polycrystalline solids
Alumina and Zirconia
Solid sintered monophase

ceramics
Procera was the first by

Nobel Biocare
Ceramics Manufacturing Methods
Hand-Stacked Heat-Pressed Machine-Milled

Powder / Liquid
Conventional
Glass +\- crystal

components
Water or special liquid
Vacuum fired
Technique sensitive
Pressable
Monochromatic ingots
Can be cut-back \ layered
IPS e.max
IPS Empress I
Pressable
Ivoclar: E.max Press
Derived from Empress II
Available as of ~2005
Lithium Disilicate based

http://www.ivoclarvivadent.us/en/products/all-ceramics/ips-
emax-technicians/ips-emax-press
Pressable
Ivoclar: ZirPress
Fluorapatite glass-ceramic ingots
Presses to ZirCAD and other ZrO2

frameworks with compatible
CTE’s.
http://www.ivoclarvivadent.us/en/products/all-ceramics/ips-emax-technician
s/ips-emax-zirpress
Pressable
Ivoclar: InLine POM
leucite based ingots
Press-to-Metal
http://www.ivoclarvivadent.us/en-us/ips-inline-system/ips-inline
CAD/CAM
Glass/Crystal
Glass/Leucite
Lithium Disilicate
Framework
Monolithic
Polylithic, “Stacked”
Chairside or Lab Lab only

CAN BE
MODEL FREE!
Monolithic
Requires physical articulation

Translates to ERROR!
Polylithic,
“Stacked”
CAN BE
MODEL FREE!
Monolithic
Model-Free Workflow:
Requires physical
articulation
Translates to ERROR!
Polylithic,
“Stacked”
Preparation can affect manufacturing method
What is the “magic” of zirconia?
n
E.max
io
at d
ns ar
pe lH
m ia
Co er
ril
l at
Composites
D M
g g
in sin
as ea
c re cr
In In
Zirconia
As resin cement thickness increases:
May et al. Dental Materials 28 (2012) e99–e109

Rx for Fracture:
Decrease thickness
Increase cement space
Sharp internal angles

Example Case for Material
Choice Selection
What we, as providers, choose…. MATTERS!
Questions to Ponder at this Point…
• Final Restorative Material?

Conservative Vs. Aggressive (Patient Related
Factors)?
Bonding or Mechanical Retention (How much
enamel)? What we, as providers, choose…. MATTERS!
Manufacturing method?
40
Example Case #2 for
Material Choice Selection
The Porcelain Fused to Metal
Crown
The Porcelain Fused to Metal
Crown
• Tried and true

• *Excellent short-term and long-term survival rates
• Labor intensive to manufacture
• Can be very esthetic
• Most of the time, they’re hideous!
Behr, M., Zeman, F., Baitinger, T., Galler, J., Koller, M., Handel, G., & Rosentritt, M. (2014).
The clinical performance of porcelain-fused-to-metal precious alloy single crowns: chipping,
recurrent caries, periodontitis, and loss of retention. The International Journal of
Prosthodontics, 27(2), 153–160. http://doi.org/10.11607/ijp.3440
Stump Shade
Stump Shade
Stump Shade
Stump Shade
Stump Shade
Stump Shade
Stump Shade
Stump Shade
Filtek Supreme Pink Opaquer
Stump Shade
Delivery
Restorative Material Choices
Feldspathics
Leucite-based Polycrystaline Ceramics
Resin-Matrix Ceramics
Lithium Disilicate
Es
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Restorative Material Choices
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Light Transmission Fracture Resistance

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How is it going
to stay on?
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In Co
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m
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Important Material Properties
Light Transmission = Refractive Index
Dispersion Strengthening
Metals and Oxide Ceramics
Modulus of Elasticity
Rekow, D., Zhang, Y., & Thompson, V. (2007). Can material properties predict survival of all-ceramic
posterior crowns? Compendium of Continuing Education in Dentistry (Jamesburg, N.J. : 1995), 28(7),
362–368; quiz 369, 386. https://doi.org/17687898
Fracture Modes of Ceramics
Compressive Force
Tensile Force
Rekow ED, Silva N, Coelho PG, Zhang Y, Guess P, Thompson VP. (2011) Performance of
Dental Ceramics: Challenges for Improvements. J Dent Res, 90(8):957-952,
Solutions
The MCR to Protect the Inner Ceramic Surface
or PFZ
Increase crystalline structure
Resin Adhesives
Increase thickness
All-Ceramic MCR / PFZ

Fracture Modes of Ceramics
Rekow D, Zhang Y, Thompson V. Can material properties predict survival of all-ceramic

posterior crowns? Compendium. 2007;28(7):362-69
Flexural Strength
“How many MPa’s”?
The ability of a material to resist deformation under load

Fracture Toughness
resist fracture, and is one of the most important properties of a
edict survival of all-ceramic posterior crowns? Compendium of Continuing Education in Dentistry (Jamesbu
Fracture Toughness
Weibull Modulus of chairside ceramic Materials
Wendler, M., Belli, R., Petschelt, A., Mevec, D., Harrer, W., Lube, T., … Lohbauer, U. (2017).
Chairside CAD/CAM materials. Part 2: Flexural strength testing. Dental Materials, 33(1), 99–
109. http://doi.org/10.1016/j.dental.2016.10.008
Summary of Material Properties
Flexural Modulus Fracture Toughness

Material Flexural Strength (MPa)
(GPa) (MPA m1/2) (KIc)
Gold Alloy (Type 3) 700-760 90-100 ~20
Zirconia (Y-TZP) 900-1200 205-220 9-10
“Translucent” Zirconia 500-800 76-105 5.5-6.5
CeraSmart 160-235 8.3-12 2.6
e.max CAD 360-380 67-95 2-2.5
Celtra Duo (Unsintered / 210/370 61/63 2.11/2.24

Sintered)
Vita Suprinity 420-540 70 2.0
Lava Ultimate 200 13-16 2.0
Paradigm MZ100 150-190 8-14 1.87
Enamic 160-200 21-30 1.5
Empress CAD 160-185 62 1.3
Vita Bloc Mark II 115-155 45-65 1.18

Dicor: What did we learn?
Malament, K. a, & Socransky, S. S. (2009). Survival of Dicor glass-ceramic dental restorations

over 20 years: Part IV. The effects of combinations of variables. The International Journal of
Prosthodontics, 23(2), 134–40. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20305851
Dicor: What did we learn?
eramic dental restorations over 20 years: Part IV. The effects of combinations of variables. The In
• Came out in 1991
• Feldspathic Ceramic
• 150 MPa flexural strength
• Must be resin bonded with an adhesive resin
• No need for post-mill sintering
• Easy to mill
• Easy to polish
https://www.vita-zahnfabrik.com/en/VITABLOCS-Mark-II-25030,27568.html
• “Gold Standard” in
adhesive bonding
• Indicated for Inlays,
Onlays, and Partial
Crowns
https://www.vita-zahnfabrik.com/en/VITABLOCS-Mark-II-25030,27568.html
Belli, R., Wendler, M., de Ligny, D., Cicconi, M. R., Petschelt, A., Peterlik, H., & Lohbauer, U.
(2017). Chairside CAD/CAM materials. Part 1: Measurement of elastic constants and
microstructural characterization. Dental Materials, 33(1), 84–98.
http://doi.org/10.1016/j.dental.2016.10.009
• Leucite Reinforced Ceramic
• Successor to ProCAD
• 160-185 MPa flexural strength
• Easy to mill
• Easy to polish
http://www.ivoclarvivadent.com/en/p/all/products/chairside-cad-cam-blocks/ips-empress-
cad-chairside
• Leucite crystals are 1-5µm
• Crystals are 35-45% by
volume
• Indicated for Veneers, Inlays,
Onlays, and Crowns
http://www.ivoclarvivadent.com/en/p/all/products/chairside-cad-cam-blocks/ips-empress-
cad-chairside
Veneer Anterior Crown Posterior Crown
://www.ivoclarvivadent.com/en/p/all/products/chairside-cad-cam-blocks/ips-empress-cad-chairside
• Processed Z100
• Easy to mill
• Easy to polish
multimedia.3m.com/mws/media/77596O/paradigmtm-mz100-block-for-cerecr-technical-product-pro
• Composite resin
material
• 85% zirconia-silica
ceramic by weight
multimedia.3m.com/mws/media/77596O/paradigmtm-mz100-block-for-cerecr-technical-product-pro
e.max CAD and e.max Press
e.max CAD e.max Press

• Lithium Disilicate Ceramic
• Does not necessitate adhesive bonding
• Need for post-mill sintering
• Difficult to mill
https://www.makeitemax.com/all-ceramics/ips-emax-cad/
40% lithium 70% lithium
metasilicate crystals disilicate crystals
IPS e.max ® CAD Scientific Documentation. (2009).

• Indicated for:
• Thin Veneers
• Occlusal veneers
• Inlays\onlays
• Crowns
• Implant “hybrid” abutments / crowns
• 3-unit bridges (up to 2nd premolar)
Survival Rate of the e.max Single Crown
Pieger S, Salman A, Bidra AS. (2014). Clinical Outcomes of Lithium Disilicate Single Crowns
and Partial Fixed Dental Prostheses: A systematic review. Journal of Prosthetic Dentistry,
112:22-30.
Survival Rate of the e.max FDP
Author Year Time Observed # of Restorations # of Patients Survival Rate

2008 4 30 21 87%
Esquivel-Upshaw et al.
2012 10 36 28 87.9%
Kern et al.
2006 5 31 27 78%
Marquardt and Strub

2006 2 20 15 50%
Taskonak and Sertgoz

2010 6 18 18 63%
Makarouna et al.
2013 10 21 19 71.4%
Pieger S, Salman A, Bidra AS. (2014). Clinical Outcomes of Lithium Disilicate Single
Sola-Ruiz
Crowns and et Partial
al. Fixed Dental Prostheses: A systematic review. Journal of Prosthetic
Dentistry, 112:22-30.
What about all these new “Hybrid
Ceramics” and newer CAD\CAM blocks?
Ceramic Crowns Vs Composite Crowns
Magne, P., & Belser, U. C. (2003). Porcelain versus composite inlays/onlays: effects of
mechanical loads on stress distribution, adhesion, and crown flexure. Int J Periodontics
Restorative Dent, 23, 543–555.
Ceramic Crowns Vs Composite Crowns
• The amount of tension at the Dentin-Adhesive
interface increases as the flexibility of the material
increases
Physical Properties: Ceramics > Composites

Millabilitiy: Composites > Ceramics
Magne, P., & Belser, U. C. (2003). Porcelain versus composite inlays/onlays: effects of
mechanical loads on stress distribution, adhesion, and crown flexure. Int J Periodontics
Restorative Dent, 23, 543–555.
Awada, A., & Nathanson, D. (2015). Mechanical properties of resin-ceramic CAD/CAM

restorative materials Presented at the American Association of Dental
Research/Canadian Association of Dental Research Annual Meeting, Charlotte, NC,
March 2014. Journal of Prosthetic Dentistry, 114(4), 587–593.
Lava Ultimate

• A “Resin Nano Ceramic”
• Easy to mill
• Easy to polish
Photo from - http://www.3m.com/3M/en_US/dental-us/products/lava-ultimate/

Lava Ultimate
• “Nanoceramics" 80%
content by weight
• “Nanoclusters” of
zirconia-silica (0.6-
10µm)
• Silica = 20nm
• Zirconia = 4-11nm
3M, E. (n.d.). Lava Ultimate: Technical Product Profile. Rely X Post, 1–28.
Lava Ultimate
3M, E. (n.d.). Lava Ultimate: Technical Product Profile. Rely X Post, 1–28.
Lava Ultimate
• 1.5mm reduction requirement
• Maximize mechanical retention
• Restoration must be sandblasted with

Aluminum oxide or CoJet (≤50µm @ 2
bar)
Photos from - http://multimedia.3m.com/mws/media/747392O/lava-ultimate-restorative-

instructions-for-use-english.pdf
Lava “Ultimate”: What are we learning?
• Effective June 2015: no longer indicated for crowns
Photo from - http://multimedia.3m.com/mws/media/1198023O/lava-ultimate-restorative-

change-of-indication-notice.pdf
Annual Survival Rates at 5 years for Single Crowns
Sailer, I., Makarov, N. A., Thoma, D. S., Zwahlen, M., & Pjetursson, B. E. (2015). All-ceramic or
metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the
survival and complication rates. Part I: Single crowns (SCs). Dental Materials, 31(6), 603–623.
• A “Flexible Nano Ceramic”
• Easy to mill
• Easy to polish
http://www.gcamerica.com/lab/products/CERASMART/GCA_CERASMART_Bro-iPad.pdf
http://www.gcamerica.com/lab/products/CERASMART/index.php
• Composite resin
material 71% silica and
barium glass
nanoparticles by
weight
• 1.5mm reduction requirement
• Restoration should be sandblasted with Aluminum oxide

or CoJet (≤50µm @ 2 bar)… OR…
• HF acid etch for 60 seconds (If sandblasting not

available)
• MUST apply silane
http://www.gcamerica.com/lab/products/CERASMART/Statement%20of%20Cerasmart%202015%20PR.pdf
http://www.gcamerica.com/lab/products/CERASMART/Statement%20of%20Cerasmart%202015%20PR.pdf
• “Dual Ceramic Polymer Network”
• Must be resin bonded
• Easy to mill
• Easy to polish
http://vitanorthamerica.com/products/cadcam/vita-enamic/
• Porous ceramic network
• Mainly feldspar with Aluminum oxide
• Ceramic is 86% by weight / 75% volume
• Polymer is 14% by weight / 25% volume
• Recommended 60 seconds HF etch, followed by
Silane
Zahnfabrik H. Rauter GmbH & Co.KG. (2013). Vita Enamic - Technical and scientific
documentation, 1–36.
• Single unit restorations only
• Can be used for implant restorations
• High Weibull modulus
Zahnfabrik H. Rauter GmbH & Co.KG. (2013). Vita Enamic - Technical and scientific
documentation, 1–36.
• Came out in May 2016
• “Zirconia Reinforced Lithium Silicate”
• 420 MPa Flexural Strength
• Indicated for single-unit anything
• Must be sintered post-mill
• Can also be layered\veneered
Pc, V. S., Farbkommunikation, V., & Pc, V. S. (n.d.). Vita suprinity pc ® Working Instructions, (5).
• ~10% Zirconia
• ~60% Silica
• ~20% Lithium Oxide
Pc, V. S., Farbkommunikation, V., & Pc, V. S. (n.d.). Vita suprinity pc ® Working Instructions,
(5).
Belli, R., Wendler, M., de Ligny, D., Cicconi, M. R., Petschelt, A., Peterlik, H., & Lohbauer, U.
(2017). Chairside CAD/CAM materials. Part 1: Measurement of elastic constants and
microstructural characterization. Dental Materials, 33(1), 84–98.
Pc, V. S., Farbkommunikation, V., & Pc, V. S. (n.d.). Vita suprinity pc ® Working Instructions, (5).
• Came out in February 2016
• Adhesive or Self-adhesive Resin Cements
Recommended
• Optional firing Post-Mill for increased strength:
• 210MPa Flexural Strength (Post-Mill)
• 370MPa Flexural Strength (Sintered)
https://www.dentsply.com/content/dam/dentsply/pim/manufacturer/Restorative/
Indirect_Restoration/Ceramics/CAD_CAM_Ceramics/CELTRA_DUO/Celtra-rv9hg78-en-1402
• 10% zirconia in silica matrix
• remaining composition distribution
unknown
• Recommended 30 seconds HF etch,
followed by Silane
• Celtra Duo
• Celtra CAD
• Celtra Press
http://s3-eu-west-1.amazonaws.com/core3d-website/content/pdfs/celtra-duo-instructions-
for-use-guide-english.pdf
Zirconia and “Zirconia”
“Opaque” vs. “Translucent” Zirconia
Photo from – http://www.kuraraynoritake.com/products/cad-cam/katana-zirconia-utml-stml/
Opaque Translucent
zirconia zirconia
Zhang, F., Inokoshi, M., Batuk, M., Hadermann, J., Naert, I., Meerbeek, B. Van, & Vleugels, J.
(2017). Strength , toughness and aging stability of highly-translucent Y-TZP ceramics for
dental. Dental Materials, 32(12), e327–e337. http://doi.org/10.1016/j.dental.2016.09.025
Firing Temperature Effects on Zirconia
Crack Resistance
Light Transmission
Stawarczyk, B., Ozcan, M., Hallmann, L., Ender, A., Mehl, A., & Hommerlet, C. H. F. (2013).
The effect of zirconia sintering temperature on flexural strength, grain size, and contrast ratio.
Clinical Oral Investigations, 17(1), 269–274. http://doi.org/10.1007/s00784-012-0692-6
Mechanical Properties
Leucite Lithium Zirconia
Reinforced Disilicate
Flexural 80-160 Mpa 360-420 Mpa 900-1400 Mpa
Strength
Modulus 67 Gpa ~104 Gpa ~210 Gpa
Elasticity
Fracture 1.4MPa/m0.5 ~3.3MPa/m0.5 ~10MPa/m0.5

Toughness
Zirconia Phases
Phase Monoclinic Tetragonal Cubic

Grain 4% Larger
Size Than Tetragonal
Smallest Largest
Photo from – Hannink RHJ, Kelly M, Muddle BC. (2000) Transformation toughening in zirconia
– containing ceramics. J Am Ceram Soc. 83:461-487.
Large Cubic Phase with Surrounding Tetragonal Phases
• Too much Yttria?
Denry, I. (2013). How and when does fabrication damage adversely affect the clinical
performance of ceramic restorations? Dental Materials : Official Publication of the Academy of
Dental Materials, 29(1), 85–96. http://doi.org/10.1016/j.dental.2012.07.001
Porosity in Yttria-Stabilized Zirconia
Flaws in Zirconia: fracture occurs on grain boundaries
Irregular Grain Sizes
• Irregular Distribution of Dopants

• Surface Damage!!
Basu, B., Vleugels, J., & Van Der Biest, O. (2004). Transformation behaviour of tetragonal
zirconia: Role of dopant content and distribution. Materials Science and Engineering A,
366(2), 338–347. http://doi.org/10.1016/j.msea.2003.08.063
Transformation Toughening
142
ADL PFM Retainer Designs
ADL PFZ Retainer Designs?
“Hooded” Porcelain Fused to Zirconia Design
Bonding to Restorative
Materials
Photo from -Panaghiotis B, Magne P. (2011) Bio-Emulation: Biomimetically Emulating Nature

Utilizing a Histo-Anatomic Approach; Structural Analysis. Eur J of Esthet Dent 6(1):8-19
Adhesive Cementation Matters!
Ivoclar All-Ceramic Chairside Preparation Guide for IPS e.max, Oct 2016
Principles of Adhesion
Mechanical Chemical
Surface Area
Interlocking Bonding
Wetting/
Surface Free Viscosity Kinetics
Energy
Wetting: Contact Angle
Photo from - http://www.biolinscientific.com/attension/applications/?card=AA7

151
Wettability: Contact Angle and Surface Energy
Photo from - http://www.adhesives.org/adhesives-sealants/science-of-adhesion/wetting

152
Wettability: Contact Angle and Surface Energy
Photo from - 153
http://s.topkontakt.cz/images/img_product/original/01714/01714554_foto__cf9c291662.jpg
Zirconia Mechanical
Air-Particle Abrasion with and
Metals without
Tribochemical Coating
Glass-
Ceramics Chemical
Composites MPS and MDP
“Hybrids” Primers
Bonding Protocol Recommendations for Restorative Materials
Rocatec / Aluminum
CoJet Oxide
Material Examples (50µm @ (50µm @ Acid Etch Primer
2 bar) 2 bar)
Metals Gold, Titanium, X X MDP +\- MPS

Chromium Cobalt
Polycrystalines Zirconia X MDP
e.max CAD\Press 5% HF acid @
Disilicate Ceramics MPS
Vita Suprinity 20 seconds
Zirconia Reinforced Celtra Duo 5% HF acid @ MPS
Lithium Silicates 30 seconds
Leucite Reinforced Empress CAD 5% HF acid @ MPS
Ceramics 60 seconds
Predominantely Vitablocs Mark II, 5% HF acid @

Sirona Blocks, MPS
Glass Ceramics 60 seconds
Enamic
Predominately Lava Ultimate,

X MPS
Composite Cerasmart
Zirconia Bonding
+
50-100µm Alum Oxide @ 1-2 bar
Kuraray Zirconia Bonding Guide
10-Methacryloyloxydecyl dihydrogen phosphate (MDP)
Polymerizable Group Hydrophobic Group Hydrophillic Group

Bonding to Glass-Ceramics
Acid Etch Silanating Agent
Hydrofluoric Acid MPS
or
Monobond Etch &
Prime
DO NOT USE ANY AIR PARTICLE
ABRASION!
Over-etching Glass-Ceramics?
Over-etching glass-ceramics DOES decrease
flexural strength
(e.max Press: from ~385MPa down to
~315MPa @120sec)
However, the resin infiltration after bonding

significantly improves the flexural strength
(e.max Press: from ~360MPa up to ~410MPa
@120sec)
Xiaoping, L., Dongfeng, R., & Silikas, N. (2014). Effect of etching time and resin bond on
the flexural strength of IPS e.max Press glass ceramic. Dental Materials, 30(12),
e330–e336. http://doi.org/10.1016/j.dental.2014.08.373
3-Methacryloxyproyltrimethoxysilane (MPS)
Reactive Group Polymerizable Group

Monobond Etch & Prime
Self-etching Glass-ceramic primer
Etchant is ammonium polyfluoride
Silanating agent is proprietary and based

upon MPS
Tensile bond strength ~50MPa to e.max
CAD and Multilink Automix @ 24 hours
Product released to market in 2015
Photos from - https://ivoclarvivadent.us/en-us/media/media-releases/monobond-etch-prime
Scientific Documentation Monobond Etch & Prime (2015), Ivoclar Vivadent AG

Scientific Documentation Monobond Etch & Prime (2015), Ivoclar Vivadent AG

Air-Particle Abrasion and
Tribochemical Coating
“Sand Blasting”:
Aluminum Oxide Particles
Rocatec® and CoJet®
Glass Beads (AKA, “Polishing Beads”

Aluminum Oxide Abrasion
Photo from - http://multimedia.3m.com/mws/media/316727O/rocatectm-junior-bonding-system.pdf

Rocatec® or CoJet® Abrasion
Photo from - http://multimedia.3m.com/mws/media/316727O/rocatectm-junior-bonding-system.pdf

Air-Particle Abrasion on Zirconia
“The flexural strength of Y-TZP is enhanced

by airborne- particle abrasion, independent
of particle size, blasting time, air pressure,
and the presence of aging.”
May, L. G., & Soares, F. Z. M. (2017). Does air particle abrasion affect the flexural strength
and phase transformation of Y-TZP. A systematic review and meta-analysis. Dental Materials,
32(6), 827–845. http://doi.org/10.1016/j.dental.2016.03.021
Air-Particle Abrasion on Glass-
Ceramics
Addison, O., Marquis, P. M., & Fleming, G. J. P. (2017). The impact of modifying alumina air
abrasion parameters on the fracture strength of a porcelain laminate restorative material, 3,
1332–1341. http://doi.org/10.1016/j.dental.2006.11.012
Xoi mòn bằng phân tử nén khí
trong trám răng bằng Composites
“Xoi mòn bằng phân tử khí nén và trám răng bằng
silane nên được sử dụng để tăng cường liên kết
resin trong công tác chuẩn bị trám composite gián
tiếp ở phòng labo. Tuy nhiên, rất cần thêm những
nghiên cứu vitro để tính toán độ bền liên kết của
các vật liệu polyme/ sứ mới.”
Spitznagel, F. A. et al (2014). Resin bond to indirect composite and new ceramic/polymer

materials: a review of the literature., Nov-Dec;26(6):382-93. doi: 10.1111/jerd.12100
Air-Particle Abrasion on Teeth
Sức lưu giữ
Gurbuz, A., & Inan, O. (2008). Effect of airborne-particle abrasion on retentive strength in
overtapered fixed prosthodontic restorations, 39(3), 134–139.
Air-Particle Abrasion on Teeth
“After hemostatic agent contamination, the tooth

preparation cleansing protocol should use particle
abrasion with low-pressure aluminous oxide
particle or phosphoric acid etching to restore bond
strength to pre-contamination levels when using a
self-adhesive resin cement.”
Kois, Y. C. J. C. (2011). The Effect of Cleansing Protocol on the Bond Strength of Self-adhesive
Resin Cement to Dentin Contaminated with a Hemostatic Agent, 18–26.
http://doi.org/10.2341/09-308-LR1
Enamel
Mineral (88%)
Water (10%)
Organic (2%)
Enamel Bonding
RC - Restorative Composite
AR - Adhesive Resin
HL - Hybrid Layer
E - Enamel
Dentin
Mineral (50%)
Water (25%)
Organic (25%)
Dentin Surface and Depth
Near DEJ - 20,000/mm2 (1% of surface area)

- Tubule diameter = 0.63µm
Near Pulp - 45,000/mm2 (22% of surface area)

Classifications of Adhesive Resin Cements
Chemical Dual Cure

Light Cure
Cure
Self-
Total-Etch Self-Etch
Adhesive
Where’s the Etch?
Self-
Total-Etch Self-Etch
Adhesive
Etch and Primer are Etch and Primer are
Etch is separate combined in the Cement
• RelyX Ultimate
• Multilink Automix
• RelyX Veneer • Varliolink Esthetic DC\LC
• Panavia F 2.0
• Fuji Cem
• SpeedCem Plus
• Calibra Veneer • Panavia 21
• Rely X Unicem 2
• Panavia V5
• Clearfil Esthetic • Panavia SA
• NX3 Nexus • Calibra Universal
• Calibra Ceram
Clinical Tip when Etching:
Why Selective Etch?
Deeper demineralization = increased micro mechanical interlocking of adhesive.
Thicker Acid-Base Resistance Zone on enamel is thicker when Phosphoric Acid Etch.
With 35% PA etching, bond strengths of Self-Etch systems to enamel can be significantly
increased, compared with the Etch and Rinse systems.
Li, N., Nikaido, T., Alireza, S., Takagaki, T., Chen, J., Tagami, J. (2013). Phosphoric Acid-Etching Promotes Bond S
Bonding Systems
3 step Etch and Rinse (4th Generation/total etch)
etchant + primer + bonding agent
Total-Etch
etchant + (primer/bonding agent)
2 step Self Etch (6th Generation)
(etchant/primer) + bonding agent
1 step Self Etch (7th Generation, Multipurpose,
“Universal”) Self-Etch
(etchant/primer/bonding agent)
3 step etch and rinse (4th Gen)
2 step etch and rinse (5th Gen)
2 step self-etch (6th Gen)
1 step self-etch (7th Gen)
“Universal”
Matrix Metalloproteinases (MMP)
Zinc and Calcium dependent endopeptidases that degrades the collagen.
MMPs of note – MMP-2,

MMP-9, MMP-8, MMP-20
Bond Strength and Durability
2 step Etch and Rinse (5th Generation/total etch) STRONG AND DURABLE????
etchant + (primer/bonding agent)
STRONG AND DURABLE
“Universal”)
MODERATE STRENGTH AND DURABLE

Chlorhexidine
Directly inhibit MMPs

MOA – Chelates with Zinc that’s on the
MMPs
Remains on the dentin even after rinsing
Does not seem to affect bond strength
So why doesn’t everyone use it?
Simply put, there’s no in vivo data that shows using CHX helps bond
strength.
how does water play a role with bonding?
Water’s Role?

2 step Etch and Rinse (5th Generation/total etch) Allows for solvent to flow deeper into
etchant + (primer/bonding agent) dentin
“Universal”)
Hydrolyze monomer to allow for a chemical
bond
How to get “moist” dentin
Cotton pellet, high volume suction, disposable brush, lab tissue paper....
Goes MF, Pachane GC, Garcia-Godoy F. (1997) Resin bond strength with different methods to remove excess water from the dentin. Am J
Dent 10:298-301.
Magne P, Mahallati R, Bazos P, et al. (2008) Direct dentin bonding technique sensitivity when using air/suction drying steps. J Esthet
Restor Dent 20:130-138.
Is all dentin
created equal?
Dentin
Mineral (50%)
Water (25%)
Organic (25%)
Dentin Surface and Depth
Near DEJ - 20,000/mm2 (1% of surface area)

Near Pulp - 45,000/mm2 (22% of surface area)

Sclerotic Dentin
Differences in pH
Phosphoric acid ~ 0.1-0.4

Aggressive SE ~ < 1
Moderate SE ~ 1-1.9
Mild SE ~ 2.0 - the pH that allows for a chemical bond
Ultramild ~ > than 2.5
Dentin Bonding for Indirect Restorations
What’s a huge advantage of 7th Generation
Bonding Systems?
Very Low Film Thickness

As the adhesive layer increases…
May, L. G., Kelly, J. R., Bottino, M. a, & Hill, T. (2012). Effects of cement thickness and
bonding on the failure loads of CAD/CAM ceramic crowns: multi-physics FEA modeling
and monotonic testing. Dental Materials : Official Publication of the Academy of Dental
Materials, 28(8), e99-109. http://doi.org/10.1016/j.dental.2012.04.033
Immediate Dentin Sealing
Sealing the dentin with bonding agent before impression making

1) Protection of the pulp
2) Increase bond strength
Magne P, So WS, Cascione D. (2007) Immediate Dentin Sealing supports delayed
restoration placement. Journal of Prosthetic Dentistry. 98:166-174.
Make the
Apply Bonding
impression/indirect
Agent restoration
Gently abrade existing

Cement IDS coating/new layer
of bonding agent
Making the impression
Magne P, Nielsen B. (2009) Interactions between impression materials and immediate

dentin sealing. Journal of Prosthetic Dentistry, 102:298-305.
Day of Cementation
Abrades the IDS bonding agent

• Used to prep the bonding agent… now
uses air particle abrasion
Can potentially perforate the IDS BA

• Re-etches the tooth and applies more bonding
agent
• Does not cure the 2nd bonding agent
precementation
Magne P, So WS, Cascione D. (2007) Immediate Dentin

Sealing supports delayed restoration placement. Journal of
Prosthetic Dentistry. 98:166-174.
Surface Treatments after Contamination
Air & Water Syringe?

Phosphoric Acid Etch?
Hydrofluoric Acid Etch?
Isopropyl Alcohol?
Air-Particle Abrasion?
Ivoclean?
Glass-Ceramics:
DO NOT AIR-PARTICLE ABRADE!
Air-abrasion >1 bar significantly reduces
flexural strength!
Air-abrasion >2 bar reduces flexural
strength by ~ 50%!
Meenes, T., Lawson, N., Beck, P., Burgess, J. (2014) Influence of particle abrasion or
hydrofluoric acid etching on lithium disilicate flexural strength. Journal of Prosthetic Dentistry
112(5):1164-1170
Glass-Ceramics:
If contaminated by blood and saliva:
Ceramic can be cleaned with Phosphoric Acid or
with Ivoclean
Ceramic will need to be re-silanated
Bock, T., Ozcan, M. (2015) Protocol for Removal of Clinically Relevant Contaminants from
Glass Ceramic-based Restorations. Journal of Adhesive Dentistry. Aug;17(5):474-5
Zirconia:
If contamination occurs AFTER MDP application,

then rinsing with water preserves the bond
strength.
If contamination occurs BEFORE MDP

application, then air-particle abrasion or Ivoclean
are equally effective
Angkasith, P., Burgess, J., Bottino, M., Lawson, N. (2016). Cleaning methods for zirconia
following salivary contamination. Journal of Prosthodontics.25:375-379
Silicon-based Pastes Contamination
Glass-Ceramics:
Re-etching with HF acid is most effective
to improve bond strength
Re-etching with HF is NOT recommended by
manufacturers*
Fraga, S., Oliveira, S. C., Pereira, G. K. R., Beekman, P., Rippe, M. P., & Kleverlaan, C. J.
(2016). Silicone Disclosing Material used after Ceramic Surface Treatment Reduces Bond
Strength. The Journal of Adhesive Dentistry, 18(6), 545–554.
http://doi.org/10.3290/j.jad.a37358
Silicon-based pastes (ie. FitChecker) MUST

be cleaned off appropriately before bonding
Silicon-based pastes (ie. FitChecker)

NEGATIVELY affect the bond strength of
Zirconia and Lithium Disilicate
Does not affect the effect the bond strength

to DENTIN
Photos from: - https://www.pattersondental.com/Supplies/ProductFamilyDetails/PIF_58871
https://www.speareducation.com/spear-review/2012/07/predictably-marking-tight-
restorative-interdental-contacts
What is Ivoclean?
Universal cleaning agent for restorations
after try-in
Only extra oral use: VERY high pH

(~14)
Removes phosphates to prepare
restorative surfaces for bonding
NOT useful after silicon-based try-in
pastes
Photos from -
http://www.ivoclarvivadent.com/en/p/all/products/luting-material/accessories/ivoclean
Bond Strength of Glass-
Ceramics Vs. Zirconia Vs.
Dentin?
Common Bonding Mistakes/Tips:
• Expired materials
• Restoration and\or tooth contamination
• After milling, remove any debris (alcohol recommended)
• Cement layer is too thick
• Improper application of the bonding agent
• Scrubbing the tooth with the bonding agent helps
penetration into dentin tubules
• Over-drying dentin will cause collapse of the collagen and
prevent proper bonding
• Over-etching the ceramic, enamel, and/or dentin
• Under-etching the ceramic, enamel, and/or dentin
Giordano, R. (n.d.). Bonding Tips for VITA ENAMIC ®.

In Summary
Classifications of Ceramics
Material Properties of Ceramics
Ceramic Restorative Material Choices
Bonding to Enamel and Dentin
michael.r.andersen.mil@mail.mil

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CDR Michael R. Andersen, DDS, MS, FACP

Full disclosure; no financial incentives

• “An inorganic compound with nonmetallic properties

Anusavice, K., (2003)

Low mechanical properties

Varying amounts of crystal

potassium and aluminum

alters coefficient of thermal

inhibits crack propagation

2nd heat treatment nucleates

Improved mechanical and

~70% lithium disilicate by

Grain size ~0.2-1.0 microns

Solid sintered monophase

Procera was the first by

Hand-Stacked Heat-Pressed Machine-Milled

Glass +\- crystal

Water or special liquid

Can be cut-back \ layered

Ivoclar: E.max Press

Derived from Empress II

Lithium Disilicate based

Fluorapatite glass-ceramic ingots

Presses to ZirCAD and other ZrO2

leucite based ingots

Chairside or Lab Lab only

Requires physical articulation

May et al. Dental Materials 28 (2012) e99–e109

Increase cement space

Sharp internal angles

• Final Restorative Material?

• Tried and true

Light Transmission Fracture Resistance

All-Ceramic MCR / PFZ

Rekow D, Zhang Y, Thompson V. Can material properties predict survival of all-ceramic

The ability of a material to resist deformation under load

resist fracture, and is one of the most important properties of a

Flexural Modulus Fracture Toughness

Celtra Duo (Unsintered / 210/370 61/63 2.11/2.24

Empress CAD 160-185 62 1.3

Vita Bloc Mark II 115-155 45-65 1.18

Malament, K. a, & Socransky, S. S. (2009). Survival of Dicor glass-ceramic dental restorations

e.max CAD e.max Press

IPS e.max ® CAD Scientific Documentation. (2009).

Author Year Time Observed # of Restorations # of Patients Survival Rate

Marquardt and Strub

Taskonak and Sertgoz

Physical Properties: Ceramics > Composites

Awada, A., & Nathanson, D. (2015). Mechanical properties of resin-ceramic CAD/CAM

• Came out in 2011

Photo from - http://www.3m.com/3M/en_US/dental-us/products/lava-ultimate/

• 1.5mm reduction requirement

• Maximize mechanical retention

• Restoration must be sandblasted with

Photos from - http://multimedia.3m.com/mws/media/747392O/lava-ultimate-restorative-

• Effective June 2015: no longer indicated for crowns

Photo from - http://multimedia.3m.com/mws/media/1198023O/lava-ultimate-restorative-

• Restoration should be sandblasted with Aluminum oxide

• HF acid etch for 60 seconds (If sandblasting not

• MUST apply silane

Fracture 1.4MPa/m0.5 ~3.3MPa/m0.5 ~10MPa/m0.5

Phase Monoclinic Tetragonal Cubic

• Too much Yttria?