A NE ALW L G T E H N ATE R G A LI TIO T N E R O S F DEN I T S A L N C OTE R G A O M L I D CS by Mark Gervais

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2 A NEW ALL THAT GENERATION GLITTERS OF DENTAL IS NOT CERAMICS GOLD by Mark Gervais

3 The next 28 minutes Material classifications Bonded veneers & partial coverage restorations Conventional crowns & bridges Dental implants The future of dental ceramics A new generation of dental ceramics

4 MATERIAL CLASSIFICATIONS CERAMICS

5 Material classification I According to ceramic composition 1. Conventional veneering porcelains 2. Particle reinforced glasses 3. Polycrystalline ceramics Kelly Griggs JR JA (2004). (2007). Dental Recent ceramics: advances Current in materials thinking for all-ceramic and trends. restorations. Dental Clinics of North America; 48(2): (3):

6 Material classification II According to ceramic manufacture 1. Conventional sintering technique 2. Casting / pressing technique 3. Milling technique (CAD/CAM) (Computer aided design / computer aided machining)

7 Material ETCHABLE classification CERAMICS III SILICA-BASED CERAMICS i) Conventional veneering porcelains ii) Particle reinforced glasses (eg. IPS Empress, IPS e.max Press, Finesse) NON-ETCHABLE CERAMICS INGOTS FOR CAD-CAM TECHNOLOGY iii) iv) Slip-cast ceramics (eg. VITA In-Ceram Spinell / Alumina / Zirconia, NobelProcera Crown Alumina) Polycrystalline ceramics Material classification III (eg. Lava Zirconia, VITA In Ceram YZ, IPS e.max ZirCAD, NobelProcera Zirconia)

8 BONDED VENEERS and PARTIAL COVERAGE RESTORATIONS A new generation of dental ceramics

9 Conventional veneers

10 What s the biologic cost? Conventional crowns

11 What s can the we biologic do better? cost?

12 Partial coverage restorations

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14 the best material for bonded veneers & partial coverage restorations?

15 ETCHABLE CERAMICS SILICA-BASED CERAMICS i) Conventional veneering porcelains ii) Particle reinforced glasses (eg. IPS Empress, IPS e.max Press, Finesse) NON-ETCHABLE CERAMICS INGOTS FOR CAD-CAM TECHNOLOGY iii) iv) Slip-cast ceramics (eg. VITA In-Ceram Spinell / Alumina / Zirconia, NobelProcera Crown Alumina) Polycrystalline ceramics (eg. Lava Zirconia, VITA In Ceram YZ, IPS e.max ZirCAD, NobelProcera Zirconia)

16 IPS Empress (leucite-reinforced glass ) 20 second etch with hydrofluoric acid 2 µm

17 IPS e.max Press (lithium disilicate) 20 second etch with hydrofluoric acid

18 Magne P, Belser U (2002) Bonded porcelain restorations in the anterior dentition. A biomimetic approach. Quintessence Books. 1 st edition

19 CONVENTIONAL CROWNS and BRIDGES A new generation of dental ceramics

20 (Friadent, Ankylos 2006) (Neoss 2007)

21 IPS Empress with veneering porcelain

22 IPS e.max ZirCAD coping with veneering porcelain

23 What s the biologic cost?

24 Zirconia

25 What are zirconia-based ceramics? Three different materials: 1. Zirconia toughened ceramics = a dispersion of zirconia particles into another matrix. 2. Partially eg. In-Ceram stabilized Zirconia zirconia (zirconia-toughened = tetragonal zirconia alumina, a or matrix ZTA). of stabilized cubic zirconia. Additions such as CaO, MgO, and Y2O3 3. Tetragonal allow zirconia partial polycrystals stabilisation = uniform, of the ZrO2. densely packed grains eg. (yttria-doped Denzir-M of metastable (magnesium-doped tetragonal zirconia. zirconia Grain PSZ). polycrystals, size is controlled or Y-TZP). by the type and concentration of dopant material. eg. Lava Zirconia, In-Ceram YZ, e.max ZirCAD, Procera Zirconia (yttria-doped tetragonal zirconia polycrystals, or Y-TZP). Adapted from: Kelly JR, Denry I (2008). Stabilized zirconia as a structural ceramic. Dental Materials; 24(3):

26 The anatomy of zirconia (Y-TZP) Grain of zirconia Tetragonal crystal structure

27 The anatomy of zirconia (Y-TZP) Crystal structures controlled Kelly JR, by grain Denry size I (2008) which is dependant on Stabilized yttrium concentration zirconia as a structural ceramic. Dental Materials; 24(3): Cubic 2370 C Tetragonal 1170 C Monoclinic crystal structure

28 Construction of Y-TZP prostheses Pre-sintered blocks

29 Construction of Y-TZP prostheses Pre-sintered blocks Computer aided design (CAD) Computer aided manufacture (CAM)

30 Construction of Y-TZP prostheses Y-TZP Pre-sintered blocks Computer aided design (CAD) Computer aided manufacture (CAM) Sintering process

31 Yttria-doped tetragonal zirconia polycrystals (Y-TZP) 4.5% increased volume Y-TZP Monoclinic crystal structure STABLE at room temperature Tetragonal crystal structure METASTABLE at room temperature

32 Construction Completed Y-TZP of a Y-TZP prosthesis prosthesis Y-TZP framework Veneering porcelain

33 Mechanical properties Guazzato M, Albakry M, Ringer SP, et al. (2004). Strength, fracture toughness and microstructure of a selection of all-ceramic materials. Part I. Pressable and alumina glass-infiltrated ceramics. Dental Materials; 20(5): Guazzato M, Albakry M, Ringer SP, et al. (2004). Strength, fracture toughness and microstructure of a selection of all-ceramic materials. Part II. Zirconia-based dental ceramics. Dental Materials; 20(5): Piconi C, Maccauro G (1999). Zirconia as a ceramic biomaterial. Biomaterials; 20(1):1-25.

34 Special properties of Y-TZP Phase transformation CRACK CLOSES initiates transformation zone Tetragonal turns to monoclinic with 4.5% volume increase Y-TZP

35 The limitations of Y-TZP prostheses Bonding Unlike silica-based ceramics, Y-TZP ceramics cannot be acid etched and the profession has struggled to achieve predictable bonding regimes. Aboushelib Yang Tanaka Lohbauer Atsu Conrad SS, B, HJ, R, Scharnberg Kilicarslan U, Fujishima MN, Seong Zipperle Matinlinna W-J, MA, M, Wolfhart Shibata Pesun Kucukesmen Rischka JP, Salameh IJ, Y, S, K, et et al. HC, al. Z, (2007). (2008). et al. (2006). (2008). Innovations Hydroxylation Influence Microtensile Effect Current of ceramic zirconium-oxide of contamination of bonding materials dental strength to ceramic zirconia-based and of different bonding systems surfaces: components to with materials: zirconia Characterisation treatments clinical ceramic. of Part recommendations: core I. the veneered and bond bonding all-ceramic strength A systematic potential. to adhesive restorations. review. resin. Dental Journal Materials; of Biomedical 24(9): Materials Research; 81B(2): Journal of Biomedical Dental Prosthetic Research; Dentistry; Materials 87(7): (6): (5): Research; 87B(2):

36 The limitations of Y-TZP prostheses Bonding Space for materials

37 What s the biologic cost of treatment?

38 Space for materials 1.5mm 1.5mm 1.2mm 1.2mm 1.0mm 1.0mm Y-TZP 3-unit bridge preparation

39 All-ceramic tooth preparation Ceramo-metal tooth preparation

40 The trouble with Y-TZP prostheses Veneering ceramics Problems with the porcelain veneer seem to trouble most studies dealing with Y-TZP. These troubles are most likely due to stresses in the zirconia - porcelain interface. Aboushelib Denry Guazzato Kler I, M, Kelly M, De MN, Proos JR Jager Kleverlaan (2008). K, N, Quach Meegdees CJ, L, Feilzer et al. M, (2004). et AJ, al. (2006). et (2007). al. (2008). Effect Microtensile Influence State Strength, of the zirconia reliability, of art thermal bond of type zirconia strength and expansion mode its for of bond dental different of mismatch fracture strength applications. components of and bilayered fatigue of loading core veneered on phase porcelain/zirconia changes Dental with all-ceramic Materials; different restorations. (Y-TZP) 24(3): veneered dental ceramics. Part Y-TZP ceramics. II: Zirconia zirconia veneering discs. ceramics. Journal Dental Biomaterials; Materials; of Prosthodontics; Oral 25(20): Rehabilitation; 22(9): (5): (11):

41 The BIG trouble with Y-TZP Longevity questions

42 The BIG trouble with Y-TZP Fatigue & low temperature degradation CRACK CLOSES initiates transformation zone Tetragonal turns to monoclinic with 4.5% volume increase Y-TZP

43 The BIG trouble with Y-TZP Fatigue & low temperature degradation Transformed monoclinic zone Decreased strength. Increased susceptibility to degradation. Grain pull-out & micro-cracking. Metastable tetragonal crystal structure Y-TZP

44 The BIG trouble with Y-TZP Degradation process 1. T-M transition starts on the surface and progresses into the material bulk. 2. Degradation encouraged by surface flaws, mechanical damage, and temp increases. 3. T-M transition is enhanced in water. Lawson S (1995). Environmental degradation of zirconia ceramics. Journal of the European Ceramic Society; 15(6):

45 The BIG trouble with Y-TZP Degradation promotion CAD/CAM machining Surface grinding Sandblasting Firing of veneering porcelain Finishing procedures (eg. polishing) Moisture Luthardt Kosmač Zhang Øilo Papanagiotou Studart M, Y, Gjerdet AR, T, RG, Lawn Oblak Filser Holzhüter HP, BR, NR, C, F, Morgano Rekow Tvinnereim Jevnikar Kocher MS, ED, SM, Rudolf P, P, et HM et Giordano al. al. H, (2008). (2007). (2004). (1999). et al. RA, (2004). et al. (2006). Effect The In CAD/CAM-machining vitro firing effect of evaluation lifetime sandblasting procedure of surface of dental of low-temperature influences grinding effects on ceramics the long-term and properties Y-TZP under sandblasting aging performance zirconia. cyclic of effects a loading zirconia flexural and of in dental core finishing water. strength ceramic. ceramics. procedures and Journal Dental Biomaterials; reliability Materials; of on Biomedical of the 28(17): Y-TZP flexural 24(4): (7): zirconia Materials strength ceramic. and Research; structural stability 71B(2): of Y-TZP. Journal Dental Materials; of Prosthetic 15(6): Dentistry; 96(3):

46 A bridge too far.

47 DENTAL IMPLANTS A new generation of dental ceramics

48 (Friadent, Ankylos 2006) (Neoss 2007)

49

50 ? Neoss Neolink system

51 THE FUTURE OF DENTAL CERAMICS A new generation of dental ceramics

52 The future of dental ceramics Dental implants made from zirconia. Stanford C, Estafanous E, Neppalli K, et al. (editors) (2008). Zirconia is invading implant dentistry! A material with great potential and concern. Int Journal of Oral & Maxillofacial Implants; 23(6):

53 The future of dental ceramics Dental implants made from zirconia. Zirconia coating over titanium implants. Sollazzo V, Pezzetti F, Scarano A, et al. (2008). Zirconia oxide coating improves osseointegration in vivo. Dental Materials; 24(5)

54 The future of dental ceramics Dental implants made from zirconia. Zirconia coating over titanium implants. Y-TZP surface made etchable using ceramic glaze. Cattell MJ, Chadwick TC, Knowles JC, et al. (2009). The development and testing of glaze materials for application to the fit surface of dental ceramic restorations. Dental Materials; 25(4):

55 The future of dental ceramics Dental implants made from zirconia. Zirconia coating over titanium implants. Y-TZP surface made etchable using ceramic glaze. CAD/CAM surface sintered to Y-TZP coping. Beuer F, Schweiger J, Eichberger M, et al. (2009). High-strength CAD/CAM-fabricated veneering material sintered to zirconia copings a new fabrication mode for all-ceramic restorations. Dental Materials; 25(1):

56 Conclusions Material classifications A new generation of dental ceramics

57 COMPOSITION: MANUFACTURE: Particle COMPOSITION: reinforced glass Polycrystalline ceramic COMPOSITION: Casting / pressing technique Particle reinforced glass MANUFACTURE: Milling technique (CAD/CAM) MANUFACTURE: Milling technique (CAD/CAM) COMPOSITION: MANUFACTURE: Conventional veneering porcelain Conventional sintering technique

58 Conclusions Use etchable ceramics for bonded restorations. (eg. Conventional porcelain, IPS Empress, Finesse) A new generation of dental ceramics

59 Conclusions Use etchable ceramics for bonded restorations. Use all-ceramic crowns & bridges judiciously. Ceramo-metal prostheses are still the benchmark on posterior teeth. What s the biologic cost of treatment? The future of dental ceramics is exciting. Approach new products with healthy skepticism, and understand the materials before you use them. A new generation of dental ceramics

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61 Mark J Gervais March 2009 THE END

62 Dr Mark J Gervais BDSc (Qld), DipClinDent, DCD (Melb) Registered Prosthodontist

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66 Enamel bonding to etched ceramic

67 ETCHABLE CERAMICS SILICA-BASED CERAMICS i) Conventional veneering porcelains ii) Particle reinforced glasses NON-ETCHABLE CERAMICS INGOTS FOR CAD-CAM TECHNOLOGY iii) iv) Slip-cast ceramics Polycrystalline ceramics

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