Prep Design Hands-on (Womens Leadership Conference in Phoenix, AZ)

All-Ceramics:

Whats New? Whats Proven? Controversies and Clinical Tips!

Dr. Damon C. Adams, a graduate of the University of Michigan School of

Dentistry, is an assistant clinical professor at the University of Toledo, College of
Medicine, Division of Dentistry. He lectures internationally focusing on updates in
dental materials, the latest trends and innovations in dentistry, doctor-technician
relationships, and techno-clinical perspectives. Dr. Adams is the editor-in-chief of
Dentistry Today and is listed in Dentistry Todays Leaders in Continuing
Education.

Dr. Adams is a member of the ADA, AGD, AACD, SCAD, ASDA, and the
National Association of Dental Laboratories. He is a Fellow of the ICD.

Dr. Adams may be reached at 231-642-7785 or damon@drdamonadams.com

Please visit adamsdentalseminars.com for more information.

Disclosure: Dr. Adams has absolutely no financial interest in any of the dental manufacturers mentioned in his articles or lectures. He
receives no compensation of any kind from any manufacturer for writing articles or creating lecture materials. In sometimes mentioning
specific manufacturers and products in the course of his lectures and hands-on workshops, Dr. Adams is not endorsing any product or
manufacturer over another. The actual material and equipment choices that doctors and laboratory owners make are strictly their own
decision to make, and due diligence must be given in selecting specific products based upon the needs and technical/treatment goals of
all parties involved. Dr. Adams works as the editor-in-chief of Dentistry Today in an independent contractor relationship.

2016 Adams Dental Seminars LLC

All Rights Reserved
Trends, Innovations, Controversies, and Clinical Tips

Presenter: Dr. Damon Adams

6 PACE/CERP CEUs

In this information-packed scientific program, Dr. Adams, from his unique perspective as
editor-in-chief of one of North America's leading clinical and news journals, will present
an engaging presentation focused on current trends, controversies, and innovations. He
will be placing a special emphasis on a variety of clinical tips designed to assist the
dentist and team in choosing and successfully implementing the latest lab-fabricated all-
ceramic dental materials and treatment protocols. This is an exciting and candid update
on some of the most important topics in restorative dentistry that you will not want to
miss!

This half-day science-based presentation is recommended for doctors and their

team, including dental laboratory technicians.

Lecture Topics

Update on the latest trends in all-ceramics

100% zirconium restorations: A candid review and update on important

practical clinical challenges that will affect doctors and technicians in the

long-term. (Solutions will be presented.)

Material choice protocol for non-metal based restorations

6-step prep protocol for posterior all-ceramic monolithic restorations

Anatomic core build-up requirements for monolithic zirconia

A novel way to accurately treatment plan and minimally prepare for anterior

all-ceramic cases

An update on surface treatments for all-ceramics. Making it much simpler!

What are the best cements for all-ceramics available today?

All-ceramic polishing and prophy protocols for hygienists/doctors

Update on other trends and new/recent developments: novel composite

resin techniques; oral cancer detection; same-day one-hour dentures, new

technologies for endodontics, and more (as time allows)

2
Classification of All-Ceramic Systems
(Note: Product names mentioned below serve as examples; this is not an all-inclusive listing of products by category.)

Glass-Based Ceramics (mainly silica [silicone dioxide/quartz] with or w/o crystalline fillers)
Aluminosilicates, known as feldspars in nature, are modified in various ways to create glass and other synthetic ceramics.

1) Leucite-Reinforced (Low-to-moderate leucite-containing porcelains=feldspathic porcelain.)

2) Leucite-Reinforced (High leucite-containing porcelains)

Leucite reinforced copings (such as IPS Empress, IPS Empress Esthetic, Authentic, Cerpress, Finesse
Pressable, OPC) (Authentic and Finesse Pressable are examples of systems that can also be used for
pressed-to-metal applications.)
Indications: Crowns, veneers, inlays, onlays
Cementation: Bonded only (silane or a universal primer required); DC or LC (veneer) resin cements

3) Lithium Disilicate (Aluminosilicate glass with lithium oxide added)

This class of materials was introduced in the late 1990s as conventionally pressed lithium disilicate
copings layered with compatible (lithium oxide containing) porcelains (OPC 3G [Pentron], IPS Eris
[Ivoclar Vivadent]). Layered and monolithic restorations available.
Indications: Crowns, inlays, onlays and 3u anterior bridges (Note: 16 sq mm connectors!)
Cementation: Conventional cement, or bonded (preferred) with silane or universal primer and a DC or
LC (veneers) resin cement. (Preparation must have adequate retention/resistance form if conventional
cement is used.)

IPS e.max CAD (LT [low translucency] used for fabricating fully anatomical crowns/cutback and
veneering, MO [medium opacity] used for frameworks with final veneering)
Indications: Ant./Post. Crowns, partial crowns and veneers.
Conventional cement, or bonded (preferred) with silane or universal primer and a DC or LC (veneers)
resin cement.
(IPS e.max CAD LT is available for restorations fabricated selected in-office CAD/CAM systems.)

IPS e.max Press (LT, MO, HT (high translucency) lithium disilicate material.
Indications: Ant./Post. crowns, partial crowns, 3-unit anterior/3-unit premolar bridges, veneers.
Conventional cement; or bonded (preferred) with silane or universal primer and a DC or LC (veneers)
resin cement.
IPS e.max Press HT is an example of one system that allows laboratory technicians to create minimally
invasive veneers pressed (at 0.3mm-.5mm) and expands the indications to inlays and onlays.

A special note on fluorapatite glass ceramics (IPS d.Sign [Ivoclar Vivadent]):

This is a unique layering porcelain that can be used for PFMs and selected all-ceramic applications.

Polycrystalline Ceramics (Metal Oxide Ceramics)

1) Aluminum oxide
Hand painted slip that is sintered and glass infiltrated Vita In-Ceram Alumina [Vident])
Electrolayered, sintered, glass infiltrated (WolCeram Alumina [Vident])
CAD/CAM (Procera Alumina [Nobel Biocare])
Indications: Crowns, 3u anterior bridges (watch manufacturer minimum dimension requirements)
Cementation: No silane; universal primer OK. Conventional or DC resin cements.
(An additional and now rarely used subcategory: alumina magnesia (Vita Inceram Spinell [Vident]
and Wolceram [EP] Spinell [Vident])
2) Zirconium oxide (often referred to as zirconia) Layered and monolithic restorations available.
Hand-painted slip that is sintered and glass-infiltrated (In-Ceram Zirconia [Vident])
Electrolayered, sintered, glass-infiltrated (WolCeram Zirconia [Vident])
CAD/CAM Yttrium-stabilized (Y-TZP) (Lava; Lava Plus [3M ESPE]; IPS e.max ZirCAD [Ivoclar
Vivadent] ; Cercon (DENTSPLY Prosthetics); Zenostar {Ivoclar Vivadent])

Indications: Crowns, 3u-6u+ bridges (watch manufacturer maximum span requirements)

Cementation: Conventional or resin cements. No silane required. With resin cements, internal surface application
of universal primers (such as Monobond Plus [Ivoclar Vivadent]) or can use universal adhesives w/o primers.

Polymer Ceramics (or Ceramic/Polymer or also referred to as Nano Ceramics)

Note: Lava Ultimate (3M ESPE) block introduced in 2012. (Nano zirconia ceramic particles embedded in
a highly cured resin matrix. ) Enamic (Vident) introduced in 2013 and Cerasmart (GC America) in 2014.

3
Relative Strengths of Non-Metal Coping/Monolithic Systems
(Listed in order of lowest to highest relative strength)

Pressed leucite-reinforced coping systems (150 MPa) (IPS Empress, IPS Empress
Esthetic, Authentic, OPC, Cerpress, Finesse Pressable)

Polymer ceramics (Ceramic/Polymer) (230 MPa) (Lava Ultimate)

(Older) Pressed lithium disilicate coping systems (300 MPa) (IPS Eris [Ivoclar Vivadent],
OPC 3G [Pentron] (These systems are still being used in some laboratories.)

Alumina-magnesia coping systems (350 MPa) (In-Ceram Spinell, WolCeram Spinell.

Note: WolCeram is reportedly stronger due the electrolayering process and a longer sintering time.

CAD/CAM monolithic lithium disilicate systems (360 MPa) (IPS e.max CAD [Ivoclar
Vivadent]

Pressed monolithic lithium disilicate systems (400 MPa) (IPS e.max Press [Ivoclar
Vivadent])

Aluminum oxide hand-painted slip coping system (500 MPa) (In-Ceram Alumina,
WolCeram Alumina) Note: WolCeram is reportedly stronger due the electrolayering process and a
longer sintering time.

CAD/CAM Aluminum oxide coping systems (600+ MPa) (Procera AllCeram, CEREC inLab
Alumina)

Zirconium oxide hand-painted slip coping systems (700 MPa) (In-Ceram Zirconia,
WolCeram Zirconia) Note: WolCeram is reportedly stronger due the electrolayering process and a
longer sintering time.

CAD/CAM Zirconium oxide coping and monolithic systems (900-1400+ MPa) (Cercon,
Procera Zirconia, e.max ZirCAD, Lava, CEREC inLab Zirconia: Monolithic ZR (such as Zenotech, Pearl,
BruxZir, Opalite, Crystal, etc.).

4
Ability of Various Materials to Block-Out Undesirable Stump Shades/Metal
(Listed in order from most translucent to most opaque, with some examples. Note; Varying thicknesses of the
materials listed below will have an effect on relative translucency/opacity and thus the ability to transmit/block-
out underlying desirable/undesirable shades/materials.)

High translucency (These should never be used over dark stumps or metal.)

Pressed leucite-reinforced ceramic coping systems (IPS Empress Esthetic [Ivoclar

Vivadent], OPC [Pentron], Authentic [Jensen Industries], Cerpress SL [Leach and
Dillon], Finesse Pressable [DENTSPLY Ceramco])
(Caution: Highly opaque ingots, when available, can decrease overall vitality)

Alumina-magnesia coping systems (In-Ceram Spinell [VITA], WolCeram Spinell)

IPS e.max HT (high translucency) lithium disilicate material (for thin veneers)

(Although more opaque than the above copings, use caution if attempting to cover darker
or adjacent, inconsistently dark stump shades.)

Pressed lithium disilicate coping systems (IPS Eris [Ivoclar Vivadent], OPC 3G
[Pentron], e.max Press [Ivoclar Vivadent])

Moderate Translucency- Moderate Opacity (Black stumps and metal core/implant abutments
may be blocked-out significantly, but lower value may still result.)

Polymer Ceramic (Lava Ultimate [3M ESPE])

Pressed leucite-reinforced coping systems that include higher opacity ingots (e.max
Press MO [Ivoclar Vivadent], Authentic [Jensen Industries])

CAD/CAM lithium disilicate (IPS e.max CAD MO [Ivoclar Vivadent])

CAD/CAM aluminum oxide systems (Procera [Nobel Biocare], Alumina [VITA],

WolCeram Alumina)

Minimal Translucency-High Opacity (These materials are capable of covering selected dark
stump shades/metal.)

CAD/CAM zirconium oxide and yttrium stabilized zirconium oxide coping systems (Lava
[3M ESPE], Procera Zirconia [Nobel Biocare], Cercon [DENTSPLY Ceramco], Zirconia
[VITA], WolCeram Zirconia, e.max ZirCAD)

Hand-painted aluminum oxide coping systems (In-Ceram Alumina [Vident])

Hand-painted zirconium oxide coping systems (In-Ceram Zirconia [Vident])

Selected CAD lithium disilicate (e.max CAD LT [Low Translucency], e.max Press LT)

Monolithic zirconium oxide (depending on thickness, can be complete opacity)

Complete opacity (Complete block-out if metal copings extend to cover the entire margin)

Pressed-To-Metal (PTM) systems (Authentic pressed-to-metal (Jensen Industries)

PFM systems (HNOB, NOB, BM, Titanium, Platinum-palladium/high gold hybrid: Captek)

When in doubt, it is best to consult with your dental laboratory team before you begin any preparations to see
which system is best suited for the specific aesthetic/functional parameters at hand. Photos are always valuable
for use in any team decisions. If you are prescribing an all-ceramic restoration, consider taking a stump shade
and stump shade photo in addition to your regular shade and shade photo.

5
 Product Empress Esthetic IPS e.max Captek PFM Procera Lava Premise
Indirect
(belleGlassNG)

Ideal When aesthetics is When An aesthetic Traditional Aesthetically When When posterior
the primary objective aesthetics is (high gold) PFMs masks most (not aesthetics and aesthetics is the
Applications the primary porcelain all) dark strength are primary objective
objective fused to underlying tooth necessary
Not indicated in composite Gold and shades
cases with occlusal metal PFMs are
disease Not indicated Not indicated indicated in Not indicated in Not indicated in
when occlusal in cases with cases with Not indicated in cases with cases with
disease significant dynamic cases with occlusal occlusal disease
(monolithic occlusal occlusal occlusal disease disease
LD?) disease (monolithic
disease ZR?)

Primary Veneers, crowns, Single *Single Single Single crowns, *Single crowns, *Posterior inlays,
inlays and onlays crowns & 3 unit crowns crowns bridges (ZO) bridges onlays, veneers
Applications bridges, most *3 Unit through long
distal abutment bridges span bridges
2nd bicuspid Up to 4
splinted crowns
(Cantilever
(16mm2 ICs) bridges and M-
type bridges)

Preparation *Modified shoulder *Modified *Chamfer *Any margin *Chamfer or Chamfer or *Modified
*(1.0mm min. at the shoulder or margin is design modified modified shoulder or
Requirements margin); chamfer preferred *Traditional shoulder design shoulder chamfer
*1.5-2.0mm *(1.0mm min. *(.8mm min. 1.5-1.7mm *(1.0mm min. at margin *(1.0mm min. at
incisal/occlusal at the margin); at the axial wall the margin) *(1.0mm min. the margin);
reduction; 1-1.5mm *1.5-2.0mm margin); reduction; 1.5-2.0mm at the margin); *1.5 mm
lingual reduction; 1.0- incisal/occlusal 1.5-2.0mm *1.5-2.0mm incisal/occlusal 1.5-2.0mm reduction
1.5mm axial 1.0-1.5mm incisal/occlus incisal/occlu reduction incisal/occlusal incisal/occlusal
reduction lingual al reduction; sal reduction 1.5 lingual reduction; .0.8-1.0mm
(Note: All products reduction; 1.0- reduction 1.5 lingual Chamfer design
listed on this chart .3-.5mmm 1.5mm axial 1.5-1.8mm axial reduction; when used with
require rounded veneer;1- wall reduction 1.5-1.8mm Captek or as
internal line angles) 1.5mm axial reduction axial laminates
reduction reduction*

Cementation Adhesive bonding Adhesive Conventional Conventional Conventional Conventional Adhesive

with resin cements bonding and cementation cementation cementation or cementation or bonding and
Guidelines only (Silane) resin cement with any with any resin cement resin cement resin cement
or conventional cement cement (No silane) (No silane) only (Silane)
cements
(Silane)

Flexural 150 Mpa (All FS CAD 360, 1000+ Mpa 1200-1400 600+ Mpa (AO) 900-1400+ 150 Mpa
listed on this chart is Pressed 400+ Mpa Mpa
Strength before seating) Mpa
1100Mpa (ZO) (200+ Mpa
Cristobal +)

Enamel Wear Comparable to Comparable to Comparable Comparable Comparable to Comparable to Comparable to

natural enamel natural enamel to natural to natural natural enamel natural enamel natural enamel
enamel with enamel with
d.SIGN d.SIGN
porcelain porcelain

Restoration Leucite reinforced Lithium 88% compos HNOB White Aluminum oxide Zirconium Barium
core pressed disilicate ite gold (22k) or yellow or zirconium oxide Borosilicate
Composition (Stained or layered core coping with gold with core with CAD/CAM (74%)
porcelain technique) Pressed and layered layered layered cores with Bis-GMA
stained or fluorapatite fluorapatite porcelain layered (26%)
layered porcelain porcelain porcelain
porcelain;
CAD/CAM Layering
CAD/CAM
techniques in-lab

Years of 26+ yrs 20+ yrs 25+ yrs 55+ yrs 25+ yrs (AO) 16 yrs (/Lava 15+ yrs (NG)
(Eris/OPC 3G) 15 yrs (ZO) Plus 3 yrs) 20+ yrs (bG)
Clinical Use

6
Factors Affecting Restoration Selection
Dr. John C Cranham

(Note: This text is included in this handout with verbal permission from Dr. John Cranham. The original
article can be found at sundentallabs.com/wolceram.aspx)

Choose the material that's right for your patient

Perhaps nothing is more confusing than sifting through the myriad of esthetic materials to choose the right
product for any given situation. As practitioners, we have a tendency to get comfortable with one or two
materials, and then make our patients fit the material. But that is not the best way to practice dentistry.

Know your options

A much wiser method is to spend time studying the advantages of as many materials as possible so you can
consistently choose the right material to meet the demands of each individual patient. The purpose of this
selection guide is to provide you with pertinent information necessary to assist you when considering the
optimum treatment plan for your patients.

Material Selection Criteria

There are at least six factors to consider when choosing a restorative material. Let's take a look at each
factor briefly.

1. Aesthetic Risk

Typically 1.0-3.0 mm of maxillary incisal tooth structure shows at rest in a youthful smile. From
this position, if the patient has a high esthetic demand and shows a great deal of tooth structure
(more than 7 mm of lip hypermobility when smiling), choose a material that is as cosmetic as
possible.1 If the patient is not as driven by esthetics and the teeth are not too visible, it is more
sensible to choose a more durable material - even though there may be a slight esthetic
compromise.

Another consideration is whether the underlying color of the anterior teeth needs to be blocked or
if the color is to be visible through the restoration. A material should be used with enough
translucency to allow the natural color to shine through, or enough opacity to block out
unaesthetic underlying chroma.

2. Occlusal Risk

When working up the patient's case, make sure to note any evidence of intra-articulator TMJ
signs or symptoms, occlusal-muscle disorders, masticatory muscle soreness or fatigue (tension
headaches), tooth wear, tooth mobility without periodontal breakdown, or tooth migration. These
issues should be considered indicative of a high occlusal risk patient.2 Aesthetic restorations may
still be an option, but extra attention to detail is essential to develop an occlusal scheme that
ensures a harmonious stomatognathic system - minimizing stress on the restoration.

7
 3. Quantity of Remaining Enamel

One of the best reasons to preserve tooth structure during an adhesive procedure is to conserve
a maximal amount of remaining enamel, since the crystalline structure of enamel is far less
variable than dentin. Recent reviews of porcelain veneers during the past ten years suggest that,
of the restorations that failed (4%), six of seven were only partially bonded to dentin.3 While the
success rate shows the wonderful results of porcelain veneers, it also indicates a need to
preserve as much enamel as possible.

4. Quantity and Quality of Remaining Dentin

Recent studies also look at how bonding to sclerotic and carious dentin can affect bond
strength.4,5 While predictable bonding success is hard enough to obtain inside the mouth, it
seems that bond strengths may also vary depending on the kind of dentin that exists. A good rule
of thumb is to consider a traditional cemented restoration if areas of discolored dentin are present
that lack sensitivity to cold water, air blast or to preparation without anesthesia. This evidence
may indicate that the wet collagen network within the dentin has been significantly altered,
affecting the necessary optimum bond strengths.

5. Ability to Maintain 100% Isolation

If 100% isolation cannot be obtained during an adhesive procedure, failure is imminent.6 Deep
subgingival restorations, patients with limited openings (TMJ), or any area that is impossible to
isolate are pure examples of clinical situations where traditionally cemented restorations may be
indicated.

6. Desire for Maximum Tooth Conservation

Generally, it is recommended to only remove the amount of tooth structure necessary to

maximize aesthetics, obtain the necessary retention and resistance form, and preserve remaining
tooth structure.

References

1. Spear F: The maxillary central incisor edge: a key to esthetic and functional treatment planning. Compend Cant
Educ Dent 20 (6): S 12-S 16, 1999.9. Garber DA: Porcelain laminate veneers: ten years later. Part I: Tooth
preparation. J Esthet Dent 5(2):56-S9, 1993.
2. Dawson P: Evaluation, Diagnosis, and Treatment of Occlusal Problems. C.V. Mosby, 1989.

3. Dumfahrt H, Schaffer H: Porcelain laminate veneers, a retrospective evaluation after 1 to 10 years of service:
Part II: Clinical results. Int J Prothodont 13(I):9-I 8, 2000.

4. Yoshiyama M, Urayama A, Kimoch T, et al: Comparison of conventional vs self-etching adhesive bonds to

caries-affected dentin. Oper Dent 25 (3): 163-169, 2000.

5. Nakajima M, Ogata M, Okuda M, et al: Bonding to caries-affected dentin using self-etching primers. Am J Dent
12(6):309-3 14, 1999.

6. Nakabayashi N, Pashley D: Hybridization of Dental Hard Tissues. Quintessence Publishing Co., 1998.

8
 Diagnostic Wax-up RX
(Please print.)

DR.________________________________ DATE________________________

ADDRESS__________________________ PHONE (_____)________________

CITY_______________________________

STATE_____________ ZIP_____________

PATIENT'S NAME__________________________________________

AGE_______ M F

DATE NEEDED_______________________

The following information, along with detailed impressions/study models of the hard and soft
tissues, will insure optimal treatment planning results and accurate temporary restorations:

1) Main objective(s) of the treatment? (Shade change Improve smile? Align teeth?)

2) Brief outline of treatment plan? (Tooth #'s, restoration type(s), future txt. plans?)

3) This case will require:

(Please check all boxes that apply)

Opening the bite __________mm ant.

post.
Closing the bite ___________mm ant.
post.
No change in the vertical dimension

Enclosed are the following:

(Please check all boxes that apply)

Facebow enclosed
CO bite registration enclosed
CR bite registration enclosed
Bite registration taken at desired vertical

4) Should existing midline be kept? If not, please specify changes desired:

Yes No

5) Incisal edge length/smile line (Impression or model of anterior mock-up if done?)

9
 Overlap? _______mm.

Overjet? _______mm.

6) Pre-op photos and mock-up photos (if a direct composite mock-up was done) enclosed or e-
mailed?

Please include the following pre-op photos for review:

1:10 Full Face, Smiling
1:2 Anterior, non-retracted photos
Smiling
E sound,
Relaxed lips after m sound
1:2 Anterior, retracted, teeth slightly apart
1:10 Photo of facebow in place. (Patient standing with facebow level with horizon.)

How many?__ E-mailed to(Address):_______________________ On (Date): _______

7) Interpupillary plane, anterior bite registration stick and photo enclosed?

(Note: This is not recommended if interpupillary/ facial asymmetries exist.)

Yes No

8) Duplicate models after wax-up is complete?

(Strongly recommended in all cases being shipped!)

Yes No

9) Vacuum-formed (Biostar/microSTAR) provisional template(s) or:

10) Siltex Putty provisional index(s) or:

11) Siltex Putty provisional index(s) with light-body wash?

Yes No (Please circle choice above.)

12) Siltex putty preparation guide made from diagnostic wax-up?

Yes No Pre-sliced or non-sliced? (Please circle.)

13) I would like a model of the preparations that were done in the laboratory for this
diagnostic wax-up.
Yes No

__________________________ ______________
Personal Signature of Dentist License #

Please Note! It is highly recommended that the doctor cut the preps on a duplicate set of the mounted
diagnostic casts for fabrication of the diagnostic wax-up. Dental laboratory technicians do not have
access to all of the clinical information that can affect preparation design/material selection. This step
not only ensures a realistic wax-up, it can also serve as a valuable rehearsal for the in-vivo
preparations.

10
 All-Ceramic Prep Checklist
Glass Ceramics and Polycrystalline (metal oxide) Ceramics

Create a uniform and distinct 360 chamfer margin (0.7mm is ideal whenever possible) with
an 856 diamond bur of appropriate size for the tooth being prepared. The most commonly
used sizes are: -014 for very small teeth, -016 for most anterior teeth, and -018 for most
posterior teeth.

Note: With some materials and clinical situations, a uniform 360 modified shoulder preparation (1-1.2mm)
utilizing an 846KR-016 diamond bur can be indicated. Either chamfer or modified shoulders are appropriate
for high strength ceramics, a chamfer margin being more conservative. Modified shoulders are
recommended when using most pressed ceramics. Before beginning your prep, check with your dental lab
team and/or manufacturer.

Circumferential axial reduction depends on material chosen and clinical situation.

Remember to prepare all teeth utilizing multi-plane anatomic reduction for the creation of a
restoration with natural anatomic form and optimal aesthetics

As with PFMs, 1.5-2.0 mm posterior (occlusal) reduction is ideal for aesthetics and function
for most all-ceramic restorations, but there are certain exceptions to this general rule.
Pressed leucite-reinforced porcelains require 2.0mm posterior reduction; layered and
monolithic LD at 2.0mm and 1.5mm respectively; layered Zr requires1.5-2.0mm posterior
reduction. For monolithic (non-layered) ZR), occlusal reduction should be minimally
invasive at 0.3-0.5mm (anterior) to 0.5-1.0mm (posterior). Please check manufacturer guide
and with your dental laboratory team before preparing.

Minimal axial-wall height (remaining after preparation) should be 3-4mm

Incisal reduction depends on material chosen and clinical situation. If existing wear,
minimal-to-no reduction depending on length of the tooth desired in the end result.

Use a 379 (in most cases a 021-023 size) football diamond bur to create a concave surface
for optimal functional harmony

Rounded line angles throughout

Avoid the use of proximal boxes or grooves (simply not needed with most
cementation/resin bonding techniques used now)

Aesthetic cores (as well as compomer, resin ionomer or composite resin block-out), should
be placed chairside during the preparation appointment, prior to the final impression

1. All-ceramic shoulder burs for IPS Empress Esthetic, IPS Eris, IPS e.max (Ivoclar Vivadent); Authentic (Jensen),
etc.: 846 KR, 847KR, M839-014, M839-016, 379-023. These burs are also appropriate to develop porcelain butt
joint margins in aesthetic zones for PFM restorations.
2. All-ceramic chamfer burs for lithium disilicate (such as e.max Press and e.max CAD (Ivoclar Vivadent);
aluminum oxide systems like Procera (Nobel Biocare) and zirconium oxide systems such as Lava or Lava Plus
(3M ESPE), inVizion (Vita), e.max ZirCAD or Zenostar (Ivoclar Vivadent), monolithic zirconia or PFM show-no-
metal restorations: 856 (-014, -016,-018),
3. Lingual reduction burs: 379 (-018, -023)
4. Axial Reduction Logic Set (0.6mm, 1.0mm, 1.5mm, 2.0mm) (LS-7544 Axis Dental Corp)
5. Indirect composite burs for products such as Premise Indirect (belleGlass NG) (KerrLabs), Cristobal+
(DENTSPLY Ceramco), and Sinfony (3M ESPE): H34-010, 845KR-018, 845KR-025, 846-014, 846KR-016,
375R-012, 961-018, H379-014, H274-016, 849L-009

Note: Example bur numbers shown above are Axis Dental Corp, but all these burs should be readily available from other
quality bur manufacturers such as Premier, SS White, Komet, etc. Bur manufacturers often use different numbering
systems so check with your own sales representative to translate the bur numbers listed above, if necessary.

11
Basic All-Ceramic Cementation Steps
A Brief Synopsis

Dr. Damon Adams

2-2-2 Technique using a localized rinse approach

A chlorhexidine solution (such as Peridex [3M ESPE] or alcohol-free Paroex [GUM]) is used 2x daily pre-op
for 2 weeks (1 week minimum) in the to-be-prepped area(s) to get the gingiva optimally healthy; then, the 2x
daily rinses are continued through the provisional stage (usually about 2 weeks depending on lab/doctor)
and continued for 2 weeks after the restoration is seated (or until the post-op restorative check visit with the
hygienist and doctor). A post-op appointment is made to: re-examine the occlusion, check for any residual
excess cement and remove it, and to evaluate there are any other post-op findings that might need
immediate attention (sensitivity, etc.).

Basic steps for resin cementation (basic steps for zirconia and for all other all-ceramic materials):

1. Remove the provisional and clean the prep with plain flour pumice/distilled water "paste" or commercially
prepared cleaning pastes such as Consepis Scrub (Ultradent Products); Preppies or Preppies with
CHX (Whipmix), etc.
2. Try-in the final restoration
3. Universal cleaner (Ivoclean [Ivoclar Vivadent]) is applied (as directed) on internal surfaces of restoration
and rinse and dry (this universal cleaner is OK for all dental materials.
4. Universal surface primer (Monobond Plus [Ivoclar Vivadent]) as directed on the internal aspect of the
restoration, then dry.
Note: Monobond Plus is compatible with all resin cements and all lab-fabricated restorative
materials (metals, indirect composites, all-ceramics), so simply going from step 4 to step 5 is the
simplest way to proceed. However, if you are using a universal adhesive (such as Scotchbond
Universal [3M ESPE]; Optibond XTR [Kerr]; All-Bond Universal [Bisco]; etc:) in step 5 below, you
may choose to apply a thin adhesive coat to the internal aspect of the restoration in lieu of the
universal primer (see manufacturers instructions); or, in some cases, in addition to the universal
primer (after it has been dried). If not specified in the instructions, always check with the
manufacturer to verify compatibility/advisability of the specific adhesive applied over a universal
primer.
5. Bonding adhesive on tooth (if a required step for the particular resin cement being used) (light cure or not,
depending on system [see below] and type of restoration.
(Do not light cure adhesive on the tooth at this step with veneers!)
6. Apply resin cement into the restoration, then seat and cure as directed.

If you have adequate resistance and retention form, and you are instead able to utilize a
conventional/traditional (non-resin) cementation technique using glass ionomer cement or an RMGI
cement for either lithium disilicate (such as e.max) or any zirconia/zirconia-based restorations:

1. Remove the provisional and clean the prep with plain flour pumice/distilled water "paste" or Consepsis
Scrub (Ultradent Products) (my preference)
2. Try-in the final restoration
3. Universal cleaner (Ivoclean) applied as directed on internal surfaces of restoration and rinsed/dried (this
universal cleaner is OK for all dental materials) (See note below if using an RMGI)
4. Apply conventional cement into restoration and seat (and cure) as directed.
(These same steps apply for metal-based restorations [gold and PFMs] as well.)

Note: Some studies have shown that sliane (and universal primers, such as Monobond Plus, that contain a silane group)
enhance the strength of the cement bond with RMGI cements. Adding a universal primer when using an RMGI to lithium
disilicate, aluminum and zirconium oxide is, therefore, an optional step that can be done.

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To Polish, or Not to Polish All-Ceramics?

A Brief Discussion on the Need for Varying Prophy Protocols

Dr. Damon Adams

Introduction

Practicing dentistry is not an easy task! Balancing the routine of daily patient treatment with all the
requirements to run a successful business demands constant cerebration and a desire to always
do what is best to improve the patient experience. At regular intervals, in this process of the daily
routine in a restorative practice, we need to re-evaluate what we are doing and why we are doing
it. Are we employing the most current and proven dental materials? Are we implemented them in
a way that ensures restorative predictability? Are we paying attention to understanding the details
that must be incorporated into treatment planning, restoration fabrication (aesthetics and
occlusion) and delivery, and then to the ongoing health and aesthetic maintenance issues that
can have a dramatic impact on the long-term outcome for the patient?

All this seems so elementary, doesn't it? OK then, let's look at the topic at hand, the "routine"
polishing protocol, as just one part of the dental prophylaxis. Then, after reviewing the following
information, you and your dental treatment team can review your own prophy protocol. It may be
time to determine if the steps that are routinely followed in your office have been given the
thoughtful evaluation required, especially in light of the many new composite resin and all-
ceramic dental materials that are now being used in most modern restorative practices.

On Prophy/Polishing Procedures in General

Doctors and dental hygienists should always be concerned about the risk of damage to teeth due
to instrumentation and, when polishing teeth, especially those with composite and/or porcelain
restorations. The goal in any practice setting is to use materials/techniques for any necessary
polishing procedures that will minimize undue wear of the tooth surface; and yet effectively
remove stain, plaque, calculus, and any other disease-related substances.

According to the American Dental Hygienists Association (ADHA), polishing should not be
considered simply a routine procedure. In addition, it should be offered only when a dental
hygienist or dentist determines a specific need for it.1 The ADHA states that there is "minimal
therapeutic benefit" as a result of polishing. Prevention of disease, as "prophylaxis" is defined, is
achievable in the majority of patients without polishing; this is because stain and rough surfaces
are not always present; which is especially true with all-ceramic restorations of all types, including
the currently popular material choices of zirconia and lithium disilicate, whether glazed or not
glazed (properly polished by the lab team or after adjustments by the doctor). Furthermore,
scaling is the required clinical technique to remove calculus, and plaque and other tooth surface
debris can be effectively removed by proper tooth brushing.

Guidelines for Prophylaxis of Glazed All-Ceramics

Let's assume you have patients that have been restored in your own practice, or perhaps they
have had all-ceramic work done under another doctor's care (Figure 1) and then transferred into
your practice for continued care. Regardless of the circumstances, our patients under our
supervision and care need to be treated in a way that creates no (or the very least possible) harm

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to the surface gloss and luster of any existing all-ceramic restorations. Whether they have just
one glazed monolithic or layered lithium disilicate crown (such as IPS e.max [Ivoclar Vivadent]; or
2 or 3 glazed layered or monolithic zirconia crowns (such as Lava or Lava Plus [3M ESPE]); or 6
anterior pressed and microlayered and glazed lithium disilicate (IPS e.max) or leucite-reinforced
(such as IPS Empress Esthetic [Ivoclar Vivadent]) porcelain veneers; etc.; certain guidelines
related to prohylaxis for proper and non-destructive long-term maintenance should be
implemented and followed.

Routine and regular polishing at recare appointments, by using abrasive prophy pastes
on high-gloss ceramic surfaces, should be avoided. Over time, the use of these pastes may
abrade and roughen the ceramic glaze placed over many all-ceramics. (Note: In most practices,
course pastes are routinely used because they are perceived to clean faster and better.) Prophy
pastes can also contribute to the breakdown of resin-luting cements at the margins of ceramic
veneers and onlays. In addition, it is important for the dental team to inform their patients to stay
away from any highly abrasive toothpastes as a part of the daily homecare regimen.

Ultrasonic scalers are often employed to make hygiene procedures faster and easier, but
realize that this technology can damage certain all-ceramic restorations. Take great care when
using an ultrasonic scaler around the fragile margins and bonded porcelain-cement-tooth
interfaces of any all-ceramic restoration, especially bonded veneers (such as leucite reinforced
and/or lithium disilicate/feldspathic porcelains).2 Settings that are too high (aggressive) or
ultrasonic energy left in contact too long in any one area can be highly destructive to the long-
term integrity of the restoration.

Employing a less aggressive stain removal technique and educating the patient on
preventing common stains is important. When routinely using any prophy pastes during the long-
term use in cleaning and the maintenance of composite resin and all-ceramic restorations, the
clinical protocol should include the of use a fine grit prohy paste that has been proven to be the
most gentle possible. Furthermore, it must still be effective for the removal of any particular stain.
Other techniques and technologies used for certain stain removal needs (ie Prophy Jet) should
also be considered.

Polishing also removes the surface layer of the tooth, thus reducing any desirable fluoride
content. Furthermore, enamel absorbs fluoride applied professionally in the dental office equally
as well without polishing as with polishing. It is also important to be aware of the potentially
negative consequences in using acidulated fluoride rinses or pastes on certain restorations.3
Acidulated fluoride (unlike sodium fluoride) can cause surface etching/roughness on glazed
ceramic surfaces, resulting in increased staining and decreased luster. It is important to use only
a neutral fluoride in patients with glazed all-ceramic restorations. One exception within the
modern all-ceramic material category would be polished (not glazed) monolithic (also referred to
as full-contour or solid) zirconia restorations.

On Prophy Pastes

There are many polishing pastes available today, and their content and effects can vary. It is
important to recognize that not all prophy pastes are the same and, although somewhat
counterintuitive, the finer grit product can be nearly as destructive to a polished surface as the
course grit.

Several studies compared the effects of various prophy pastes and grits on polished
composite resin surfaces and ceramics. 4,5,6 These studies demonstrated that the effects of
prophy pastes vary and are not necessarily predictable when considering the fineness or
coarseness of the grit as it relates to surface damage. For example, in one of the studies using
polished composite resin disks (IPS Empress Direct [Ivoclar Vivadent]) it was found that a specific
fine grit prophy paste was as destructive to a polished surface as the course grit version of the

14
same brand.3 These studies in clearly demonstrate that there are differences in prophy pastes
that should be evaluated by your own dental office team when making buying decisions for your
hygiene department. For example, one notable fine grit paste (Proxyt (Ivoclar Vivadent) (Figure
3), was developed with the goal of being one of the more gentle and minimally abrasive prophy
pastes on the market today for the prophylaxis of patients with direct/indirect composite resin
restorations. This material, as compared to others, has been shown to be kinder to composites
and to glazed porcelain surfaces as well. The only minor challenge, although one could argue it
makes this product more green, is that this it does not come in premeasured disposable mini-
cups for dispensing; it is available only in bulk dispensing tubes (like toothpaste). Hopefully, the
manufacturer will consider making this product available in the North American markets in more
convenient and hygienic disposable uni-dose mini cups at some point in the near future. (Note: In
place of a prophy paste one could also consider using a non-abrasive toothpaste for "polishing"
any all-ceramic restorations.)

Closing Comments

When it comes to "routine" prophy procedures, care should be taken to carefully evaluate your
patients' individual needs that are based on their specific clinical presentations. Each patient will
present with a unique dental history and dental conditions, and if the history includes restorative
work, possibly with several varying restoration types, each possibly requiring different treatment
approaches. Our work in the dental office should be considered as anything but "routine". Be sure
that you and your team are following proper prophy/polishing protocols, and only when indicated.

In the author's opinion, further studies are warranted to evaluate the long-term (in vivo)
effects of a variety of the most popularly used prophy pastes on the latest glazed and polished all-
ceramic materials.

References

1. American Dental Hygienists' Association Position on Polishing Procedures, 2001

(Available for review at www.adha.org)
2. Vermilyea SG, Prasanna MK, Agar JR. Effect of ultrasonic cleaning and air polishing on
porcelain labial margin restorations. J Prosthet Dent. 1994;71:447452. '
3. Kula K, Kula TJ. The effect of topical APF foam and other fluorides on veneer porcelain
surfaces. Pediatr Dent. 1995;17:356361.
4. Yazici A.R., Antonson D.E., Campillo M., Osborn G., Antonson S.A., Munoz C. Effect of
Prophylactic Pastes on Composite Surface Gloss. J Dent Res 90 (Spec Iss A): 3046,
2011.
5. Yazici A.R., Antonson D.E., Campillo M., Osborn G., Antonson S.A., Munoz C. Effect of
Prophylactic Pastes on Ceramic Surface Gloss. J Dent Res 90 (Spec Iss A): 500, 2011.
6. Yazici A.R., Antonson D.E., Campillo M., Antonson S.A., Karaman E., Munoz C. Effect of
Prophylactic Pastes on Ceramic Surface Roughness. J Dent Res 91 (Spec Iss A): 1059,
2012.

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