Zirconia crowns for primary anterior and posterior teeth

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Zirconia crowns for primary anterior and posterior teeth
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Zirconia crowns for primary anterior and posterior teeth

  1. 1. Zirconia Crowns for Primary Anterior and Posterior Teeth CDC해운대어린이치과 김성기
  2. 2. Strip crown Open-faced SS crown discoloration total failure chipping Durable △ Retentive O Esthetic X Durable X Retentive X Preveneered SS crown Durable △ Retentive O Esthetic △ Esthetic O
  3. 3. WHAT IS ZIRCONIA? • Physical property : close to metal • Color : tooth-like • “Ceramic Steel”
  4. 4. ZIRCONIA? • Zirconium dioxide(ZrO2)
  5. 5. The word “Zirconium” is derived from the Arabic word “Zargon” which means “golden in color”.
  6. 6. Zirconia in its natural state is a polycrystalline ceramic without a glass component. It is a polymorph that occurs in three forms:
  7. 7. Pure Zirconia at room temperature occurs in the Monoclinic form and is stable to 1170 °C Above this temperature it transforms to the Tetragonal structure And further to the Cubic phase at 2370 °C
  8. 8. • The volume expansion caused by the cubic to tetragonal to monoclinic transformation induces large stresses, and these stresses cause ZrO2 to crack upon cooling from high temperatures. • When the zirconia is blended with some other oxides, the tetragonal and/or cubic phases are stabilized. • Effective dopants include magnesium oxide(MgO), yttrium oxide(Y2O3, yttria), calcium oxide(CaO), and cerium(III) oxide(Ce2O3).
  9. 9. • By adding small percentages of yttria, these phase changes are eliminated, and the resulting material has superior thermal, mechanical, and electrical properties (PSZ : partially stabilized zirconia).
  10. 10. • For dental use ; • Yttrium tetragonal polycrystals : Y-TZP • Stabilized by adding 3mol% yttria
  11. 11. 압축강도(Mpa) 인장강도(Mpa) Composite resin 70~80 30~50 Amalgam 300~500 45~60 GI 93~226 - Porcelain 150~600 30~60 ZPC 100~160 3~8 ZOE 2~14 - Ni-Cr - 400~1000 Enamel 270~400 - Dentin 230~300 40~50 ZIRCONIA 2000 900~1200
  12. 12. In the late 1960’s , the development of Zirconia as a biomaterial was refined. The first recommended use of Zirconia as a ceramic biomaterial was in the form of the ball portion of the femur head in total hip replacement.
  13. 13. Zirconia Ceramics in Dentistry Endodontic Posts Implant posts and abutments Crown and bridge frameworks – porcelain veneered
  14. 14. Its physical, mechanical (i.e., high strength, hardness, wear resistance, resistance to corrosion, modulus of elasticity similar to steel, coefficient of thermal expansion similar to iron, and elevated fracture toughness) and chemical properties make zirconia a material of interest for biomedical sciences.
  15. 15. Scanning electron microscopy(SEM) observation of fibroblasts cultured on zirconia : cells grow on the whole zirconia surface, covering it with a cellular layer.
  16. 16. 5 months later Place subgingivally
  17. 17. Dr. Jorge Casian Adem(Mexico)
  18. 18. Kinder Krown (pre-veneered) NuSmile ZR
  19. 19. Advantages of zirconia crowns • Esthetics in addition to strength • Biocompatibility • Chair-time decreased • No impression : only 1-visit
  20. 20. Monolithic Zirconia Primary Crowns Advantages • Lifelike esthetics to rival custom laboratory fabricated crowns • Proven durability in adult dentistry for more than 10 years • Good alternative for patients sensitive to nickel • Full coverage protection • Minimal chair time • Tooth reduction similar to SSC • Can be repeatedly autoclaved
  21. 21. Monolithic Zirconia Primary Crowns Disadvantages • No crimping – tooth must be prepared to fit crown • Saliva and hemorrhage must be controlled • Cost • Learning curve at outset
  22. 22. Resin-bonded luting has proved to be the best choice for Zr-ceramic restorations, although the use of conventional cementation may also be permissible.
  23. 23. Hydrofluoric acid
  24. 24. Classification of Resin Cement • Light-cured resin cement • Chemical-cured resin cement • Dual-cured resin cement
  25. 25. Classification of Resin Cement Bonding agent + ceramic primer Self-etching primer to dentin One component One component
  26. 26. • Introduced 10 years ago • Preservation of smear layer : no postoperative sensitivity • Water resistance • Fluoride release • Physical properties : similar to resin cement • Minimize the possibility of contamination by simplifying procedures
  27. 27. Bonding Mechanisms of Zirconiabased Ceramics
  28. 28. ₩9,800/g ₩10,000/g ₩18,170/g ₩14,000/g ₩10,000/g ₩13,720/g ₩11,620/g
  29. 29. • • • • Sandblast Tribochemical silica coating Silane Ceramic primer
  30. 30. RMGI Self-adhesive
  31. 31. Zirconia crowns for primary anterior teeth • Strong adhesive strength like permanent crown is not necessary • Bleeding • Passive fit : hard to hold the crown in the proper position Recommendation : Light-cured cement (resin or RMGI)
  32. 32. Dental wear
  33. 33. Dental wear is defined as tooth loss or surface damage caused by direct contact between teeth or between teeth and other materials. Dental wear, one of the physiological phenomena that are experienced in a The surface hardness and friction coefficient are lifetime, occurs as a complex form of chemicalof commonly used to estimate the degree of wear and mechanicaldental materials. Conventionally, greater restorative wear. Accordinghasscientific studies, however, there is no hardness to been believed to cause more wear. significantmore wear was expected from zirconia, as Therefore, correlation between the restoration hardness and the degree of wear of antagonistic teeth. zirconia has strong surface hardness. On the other hand, the degree of wear is more affected by the surface structure and the roughness of the restorations or environmental factors.
  34. 34. Wear of Pediatric Enamel by Different Ceramic Materials (Pilot Project) Gary Frey, DDS Davette Johnson, DDS Houston Center for Biomaterials and Biomimetics University of Texas School of Dentistry at Houston 7500 Cambridge St. Suite 5350 width height Houston, TX 77054-2008 Stylus Material X-axis wear Y-axis wear Depth 1 Zirconia 93.6 microns 98.8 microns 46 microns 3 Zirconia 118.2 microns 110.6 microns 112 microns 5 Zirconia 93.2 microns 75.1 microns 75 microns 7 Zirconia 94.8 microns 85.3 microns 41 microns 2 Alumina 100.2 microns 95.3 microns 42 microns 4 Alumina 101.6 microns 88.3 microns 57 microns 6 Alumina 94.3 microns 105.0 microns 54 microns 8 Alumina 87.3 microns 95.3 microns 66 microns Using a Leinfelder style in-vitro wear-test apparatus, 800,000 cycles
  35. 35. What about wear to opposing primary teeth? Zirconia Stylus Tips Wear screening performed with LEINFELDER testing instrument Frey et al., Houston Center for Biomaterials and Biomimetics (2012)
  36. 36. Material X-axis wear (mean/year) Y-axis wear (mean/year) Depth (mean/year) Zirconia 24.87 ㎛/year 23.03 ㎛/year 17.12 ㎛/year Alumina 23.96 ㎛/year 23.99 ㎛/year 13.70 ㎛/year Zirconia is not harmful Normal wear rates of enamel : 8-30 ㎛/year (depending on the study)
  37. 37. Post-treatment(immediate) 2010.03.1 5 1M 3M
  38. 38. 8M 10M 13M 1Y 9M
  39. 39. 2Y 2Y 5M 2Y 8M 3Y 3M
  40. 40. No excessive attrition
  41. 41. Introducing NuSmile ZR Anterior Crowns Zirconia Primary Anterior Crowns -NuSmile® ZR -Kinder Krowns -EZ Pedo -ZIRKIZ ® crowns
  42. 42. CBCT Scan
  43. 43. CBCT Scan
  44. 44. Comparison of Marginal Adaptation Crown X Crown Y
  45. 45. EZPedo
  46. 46. An Important Note for the Preparation and Placement of NuSmile ZR Crowns • For SSC’s the crown is modified and adapts to fit the prep • For NuSmile ZR Crowns, the prep must be modified to fit the crown
  47. 47. Why is Light Transmittance and Particle Size / Density Important in Pediatric Dentistry?
  48. 48. Larger particle size allows more light transmittance risking dark tooth show-through and can impact strength of zirconia Crown X Crown Y
  49. 49. 1. Microstructure Requirement for ISO 13356 that the average grain size be under 0.40µm NuSmile ZR(0.38µm) Crowns X(0.35µm) Crown Y(0.67µm)
  50. 50. Contamination show through with Crown Y Crown X Crown Y
  51. 51. Physical and chemical properties Property Bulk density Unit NuSmile Value Requirement for ISO 13356 g/cm3 6.068~6.090 ≥ 6.00 99.60 > 99.0 Chemical Composition ZrO2 + HfO2 + Y2O3 Y2O3 percent mass 5.35 4.5 to 5.4 HfO2 fraction 3.00 ≤5 Al2O3 0.21 < 0.5 Other oxides* 0.19 < 0.5 ㎛ 0.25 ± 0.05 ≤ 0.4 % 8.12 15.82 ≤ 20 ≤ 25 Biaxial flexure Strength : - before accelerated aging - after accelerated aging MPa 1200 1140 ≥ 500 ≥ 500(Decrease not more than 20%) Radioactivity Bq/kg 2.2 ≤ 200 Microstructure : - Mean linear intercept distance Maximum amount of monoclinic phase : - before accelerated aging - after accelerated aging
  52. 52. Biocompatibility Property Standard NuSmile Value Cytotoxicity ISO 10993-5 Noncytotoxic Acute Systemic Toxicity ISO 10993-11 Do not show any systemic toxicity potential. Oral Mucosa Irritation Delayed Type Hypersensitivity ISO 10993-10 ISO 10993-10 Do not possess any oral mucosa irritation potential. Do not possess any delayed hypersensitivity.
  53. 53. Internal Retention Patterns – Thickness at Cervical Margin Tapered to 0.2mm cervical margin Non-Tapered cervical margin
  54. 54. Ivoclean can be used to effectively clean zirconia. www.ivoclarvivadent.com
  55. 55. http://www.nusmilecrowns.com/tryin
  56. 56. Using Try-In Crown select crown size that is closest to original tooth size
  57. 57. Trial Fit with pink Try-In Crown Think Pink! Use of Try-In crowns prevents contamination to actual ZR crown being cemented
  58. 58. • Check fit and alignment Try-In Crowns - labial Try-In Crowns - palatal Final crowns cemented
  59. 59. Fracture load value of ZR Crowns according to the repeated heat sterilization 800 o Heat sterilized at 121 C for 20min (according to Lava Zirconia Sterilization Guidelines) Fract ure Load(N) 700 600 500 400 300 200 - Model of crowns: D5R 100 0 o - Already reannealed at 1350 C 0 5 10 15 20 25 Number of Repet it ion Repetition number increased, it was irregularly deviated from the straight line but it was not affected by the 25-repeated sterilization.
  60. 60. Methods for Controlling Hemorrhage • Move to another Tx area, then return • Pressure or interpapillary injection of vasoconstrictor • Superoxyl, ferric sulfate, hydrogen peroxide • Retraction cord
  61. 61. PREPARATION!
  62. 62. Coarse tapered diamond or carbide bur - trim 1.5-2mm off incisal edge and break interproximal contacts
  63. 63. Black stripe – 5855 Carefully prep tooth supragingivally to avoid tissue masceration
  64. 64. Green Stripe - 6852 Use a fine thin tapered diamond – create a feather-edge margin 1-2mm subgingivally Make sure no subgingival shoulders or ledges remain
  65. 65. Round line angles and point angles Overall tooth reduction = approximately 20%
  66. 66. Trial Fit with pink Try-In Crown Think Pink! Use of Try-In crowns prevents contam ination to actual ZR crown being cemented
  67. 67. Hemorrhage and Saliva Control is Important
  68. 68. Load Crown with High Performance Luting Cement (Ceramir), Resin Cement, RMGI or GI and passively seat crown
  69. 69. Tack cure when applicable and begin final clean-up
  70. 70. Introducing NuSmile ZR Posterior Crowns Zirconia Primary Posterior Crowns
  71. 71. • Science based development of anatomy • Ideal thickness for strength and minimum tooth reduction • First primary molars also available in narrow for cases with mesial-distal space loss • Sizes 1-7 for each tooth • Microscopically scratch free surface reduces wear and plaque accumulation • Knife edge (0.2mm) margin and cervical contours for optimal fit and gingival health
  72. 72. Case Selection • Utilize anytime a standard SSC would be used • Avoid cases with severe crowding or severe mesial-distal space loss • Some clinical crown remaining • Single crown placement is best for beginning cases
  73. 73. Marginal adaptation Smooth tapered margin Distal View Overhanging Margin Mesial Gingival View Thick rough margin
  74. 74. Wall Thickness – Internal Contours Irregular anatomy Crown X Thick cervical margin Crown Y
  75. 75. Using Try-In crown, select crown size closest to original tooth size and which will look most natural.
  76. 76. Tooth Preparation Use a football or coarse tapered diamond to reduce the occlusal surface of the tooth 1-2mm following occlusal contours.
  77. 77. Black stripe – 5855 Carefully prep tooth supragingivally to avoid tissue masceration. Reduce the tooth 20% overall or 0.51.25 mm on all planes of the tooth.
  78. 78. Green Stripe - 6852 Use a fine thin tapered diamond - create a feather-edge margin 1-2mm subgingivally Make sure no subgingival shoulders or ledges remain
  79. 79. Round line angles. Overall tooth reduction = approximately 20%
  80. 80. Trial fit with pink Try-In Crown
  81. 81. Hemorrhage and Saliva Control is Important
  82. 82. Load Crown with High Performance Luting Cement (Ceramir), Resin Cement, RMGI or GI and passively seat crown
  83. 83. Tack cure when applicable and begin final clean-up
  84. 84. Check occlusion and perform final clean-up after cement is set. If occlusal adjustment is needed, adjust the opposing tooth as necessary.
  85. 85. Anterior Crowns Sizes 0-6 Posterior Crowns Sizes 1-7 Dimensional increase per size 5-6%
  86. 86. - Starter Kit(Size 1-5): 20 Crowns per kit - Sizes: 0-6(Just, Universal Incisor: 1-4) - Shades: Light(LT), Extra Light(XL) Shade - Refill Kit: 3 Crowns per model - Dimensional increase per size 5-6%
  87. 87. - Starter Kit(Size 1-5): 20 Crowns per kit - Sizes: 0-6 - Shades: Light, Extra Light Shade - Refill Kit: 3 Crowns per model -Dimensional increase per size 5-6%
  88. 88. - Starter Kit(Size 2-6): 20 Crowns per kit - Sizes: 1-7 - Shades: Light, Extra Light Shade - Refill Kit: 3 Crowns per model - Dimensional increase per size 5-6%
  89. 89. - Starter Kit(Size 2-6): 20 Crowns per kit - Sizes: 1-7 - Shades: Light, Extra Light Shade - Refill Kit: 3 Crowns per model - Dimensional increase per size 5-6%
  90. 90. - Starter Kit(Size 2-6): 20 Crowns per kit - Sizes: 1-7 - Shades: Light, Extra Light Shade - Refill Kit: 3 Crowns per model - Dimensional increase per size 5-6%
  91. 91. Dimensional increase per size 5-6% Anteriors Molars
  92. 92. #D Regular Narrow
  93. 93. Clinical Cases
  94. 94. 2011.05.27 Palatal view not fully erupted Restored with composite resin
  95. 95. 3M after treatment Palatal view
  96. 96. 6M after 1st. treatment Palatal decay is found Notice : axis of tooth is inclined palatally Axis of tooth is corrected
  97. 97. 10M after 1st. Treatment / 2M after last treatment 1Y after 1st. treatment/ 4M after last treatment 1Y 8M after 1st. treatment/ 1Y after last treatment 1Y 4M after 1st. treatment/ 8M after last treatment
  98. 98. 2Y after 1st. treatment/ 1Y 4M after last treatment No excessive attrition
  99. 99. 2010.09.10
  100. 100. Post-treatment(immediate) 1M not corrected yet 2M : crossbite corrected 4M : occlusion is stable
  101. 101. 7M 1Y 3M 1Y 2Y 4M
  102. 102. 2Y 4M No excessive attrition
  103. 103. After cementation. asymmetric Reduction of incisal edge 3M
  104. 104. For low-speed contra-angel handpiece under water-cooling
  105. 105. 2013.09.04
  106. 106. Post-treatment(immediate)
  107. 107. 6 weeks later Notice : plaque accumulation on SSC and healthy gingiva on NuSmile ZR(canine)
  108. 108. 5 weeks later : the same as upper right
  109. 109. 6 weeks after the first visit
  110. 110. 2013.09.3 0
  111. 111. 2013.10.1 5
  112. 112. Size : #0
  113. 113. Sean R. Whalen, DDS Westminster, CO U.S.A.
  114. 114. Dr. Tania Roloff Hamburg GERMANY
  115. 115. 3 weeks later
  116. 116. 2 weeks later
  117. 117. 2 weeks later
  118. 118. 2 months later
  119. 119. 5 months later
  120. 120. 2013.04.15
  121. 121. 7 months later
  122. 122. Inadequate reduction of buccal bulge resulting in horizontal extension and MB Rotation
  123. 123. correct sized crown in natural alignment in a rch – no buccal rotation or overhanging mar gin
  124. 124. Post-treatment(immediate) The crown is not rotated buccally, cervical integrity is good.
  125. 125. Post-treatment occlusion Cervical integrity and the occlusion look good.
  126. 126. 1 week later
  127. 127. 1 month later
  128. 128. 4 months later
  129. 129. 5 months later
  130. 130. #4 regular
  131. 131. 1 week later
  132. 132. #4 narrow
  133. 133. kimsungki99@gmail.com

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