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New approach to bonding all-ceramic adhesive fixed partial dentures: A clinical report
¨ zcan, Dr Med Dent,a and Akkan Akkaya, DDSb Mutlu O Faculty of Dentistry, Marmara University, Istanbul, Turkey
This clinical report describes the use of intraoral silica coating and silanization in an alternative bonding procedure for a 3-unit, all-ceramic, resin-bonded fixed partial denture. (J Prosthet Dent 2002;88: 252-4.)

ll-ceramic restorations were introduced to improve esthetics in restorative dentistry. They have been suggested for use in 3-unit anterior fixed partial dentures (FPDs) and in resin-bonded FPDs.1 Clinical application of a resin-bonded FPD (RBFPD) requires a strong and a stable resin bond to the ceramic. Poorer success rates have been reported for all-ceramic inlays and posterior crowns luted with glass ionomer than those luted with composite cement.2 Previous investigations revealed that most clinical failures initiated from the cementation surfaces of adhesive restorations.3-5 Internal surfaces have been cited as the location of highest tensile stresses and/or critical flaws; these surfaces therefore need to be strengthened. Etching the inner surface of a crown or an extracoronal restoration with hydrofluoric acid followed by the application of a silane is a well-known and recommended method to increase bond strength.6-11 Hydrofluoric acid dissolves either the glassy or the crystalline components of the ceramic. According to some authors, etching silica-based ceramics with hydrofluoric acid, ammonium bifluoride, or acidulated phosphate fluoride gel creates a sufficient resin bond that can be enhanced with silane coating of the etched conventional ceramics.7,12-14 Although hydrofluoric acid is efficient in roughening feldspathic porcelain for bonding resin cement, the optimal concentration and duration of its application are not well established. This fact is reflected in the variety of concentrations of commercially available hydrofluoric acids. Moreover, no obvious correlation has been found between bond strengths with resin cement and the microscopic characteristics of feldspathic porcelain after etching.15 In 2 studies, neither etching with these solutions nor adding silane resulted in an adequate resin bond to all-ceramics.16,17 Hydrofluoric acid and acidulated phosphate fluoride may facilitate micromechanical retention, but these chemical agents have hazardous effects in vivo, including irritation of the soft tissues.18,19 Although the bond results obtained with hydrofluoric
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acid were found to be satisfactory in some studies,7,13 alternative conditioning techniques may be preferred. Recent developments in modern surface conditioning methods have resulted in improved resin-to-ceramic bond strengths.20 All of these new systems involve conditioning the substrate to produce bifunctional molecules that adhere to the surface through silane by means of a polymerizable double bond.21,22 The manufacturers of most new surface-conditioning systems require airborne particle abrasion of the surface before bonding to achieve high bond strength. One such system is silica coating. In this technique, an intraoral device is used to air-abrade the surfaces with alumina modified with silisic acid (CoJet-Sand; ESPE, Seefeld, Germany). The blasting pressure embeds silica particles on the ceramic surface, rendering the surface chemically more reactive to the resin. The shear bond strengths between resin cement and all-ceramics treated with silica coating were reported to be significantly higher than those obtained when hydrofluoric acid and aluminum oxide were used.17,22,23 Silica coating systems have been described for intraoral ceramic repair,24 but other clinical uses have not been reported. This clinical report describes the use of intraoral silica coating and silanization in an alternative bonding procedure for a 3-unit, all-ceramic RBFPD.

CLINICAL REPORT
A 32-year-old man who had lost his maxillary left lateral incisor after a car accident 4 months previously was referred from a private practice to the Department of Prosthetic Dentistry at the University of Marmara (Istanbul, Turkey). The patient’s chief complaint was his unesthetic appearance. A 3-unit, all-ceramic RBFPD was selected as the treatment of choice for conservative and esthetic reasons. Before preparations began, radiographic evaluations were conducted to ensure that the designated abutments had adequate periodontal health and root support. After the tooth preparations were complete (Fig. 1, A), an all-ceramic RBFPD was fabricated (Fig. 1, B). A satisfactory appearance was obtained after cementation (Fig. 1, C). The restoration has been in place for 1 year.
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Assistant Professor and Lecturer, Department of Prosthodontics. PhD student, Department of Prosthodontics.

252 THE JOURNAL OF PROSTHETIC DENTISTRY

¨ ZCAN AND AKKAYA O

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vig, Daugaard, Denmark). Air particle abrasion was used with a nozzle distance of approximately 10 mm from the surface at an angle of 90 degrees for 13 seconds at 2.3 psi. The conditioned surfaces were silanized with ESPESil (ESPE) and allowed to dry for 5 minutes. No airdrying was used because of possible water or oil contamination. The dentin and enamel were total etched with 37% phosphoric acid (Email Preparator; Vivadent) for 20 seconds. The dentin was conditioned (Syntac Adhesive and Primer and Heliobond; Vivadent), and an IPS Empress II (Ivoclar, Schaan, Liechtenstein) all-ceramic RBFPD was luted with a dual-polymerizing composite (Variolink II; Vivadent) in accordance with the manufacturer’s instructions. The luting agent was applied to the preparation and internal surface of the restoration with a disposable brush. The restoration was inserted with moderate pressure, and excess luting agent was carefully removed with an explorer. Under slight pressure, the restoration was light-polymerized from 3 different directions for 40 seconds (Translux; Kulzer, Dormagen, Germany). The intensity of the lightpolymerizing unit (Model 8000; Cure Rite, Williamsville, N.Y.) was 480 mW/cm2. After polymerization was completed, excess cement was removed from the margins with a periodontal scaler (HyLite, Hamburg, N.Y.). After the rubber dam was removed, the occlusion was carefully evaluated, and adjustments were made on the restoration with an intraoral porcelain finishing set (Edenta Porcelain Veneer Kit; Edenta AG Dental Produkte, Lugano, Switzerland).

SUMMARY
The use of silica coating and silanization in an alternative bonding procedure for a 3-unit, all-ceramic, resin-bonded fixed partial denture has been described. Practitioners should consider the use of this technique for the bonding of adhesive restorations.
Fig. 1. A, Palatal view of tooth preparation on maxillary left central and lateral incisors for adhesive RBFPD. B, Inner surface of IPS Empress II adhesive RBFPD after silica coating. C, Labial view of satisfactory esthetic result after 3 months.
We thank ESPE (Seefeld, Germany) for its generous donation of the testing materials.

REFERENCES
1. Kern M, Knode H, Strubb JR. The all porcelain, resin-bonded bridge. Quintessence Int 1991;22:257-62. 2. Aberg CH, van Dijken JW, Olofsson AL. Three-year comparison of fired ceramic inlays cemented with composite resin or glass ionomer cement. Acta Odontol Scand 1994;52:140-9. 3. Kelly JR, Campbell SD, Bowen HK. Fracture-surface analysis of dental ceramics. J Prosthet Dent 1989;62:536-41. 4. Kelly JR, Giordano R, Pober R, Cima MJ. Fracture surface analysis of dental ceramics: clinically failed restorations. Int J Prosthodont 1990;3:430-40. 5. Thompson JY, Rapp MM, Parker AJ. Microscopic and energy dispersive x-ray analysis of surface adaptation of dental cements to dental ceramic surfaces. J Prosthet Dent 1998;79:378-83. 6. Thurmond JW, Barkmeier WW, Wilwerding TM. Effect of porcelain surface treatments on bond strengths of composite resin bonded to porcelain. J Prosthet Dent 1994;72:355-9. 7. Stangel I, Nathanson D, Hsu CS. Shear strength of the composite bond to etched porcelain. J Dent Res 1987;66:1460-5.

The following clinical sequence was applied to bond the RBFPD with intraoral silica coating and silanization: After determining the appropriate color for the luting cement, the prepared teeth were isolated with a rubber dam. Etching and bonding agents were applied in accordance with the manufacturer’s recommendations (Variolink II; Vivadent, Schaan, Liechtenstein). Protective eyeglasses and masks were supplied for both the patient and staff. Strong evacuation for CoJet-Sand and saliva was required. The inner surface of the restoration was air-abraded with an intraoral device (Dento-Prep; RønSEPTEMBER 2002

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8. Nicholls JI. Tensile bond to resin cements to porcelain veneers. J Prosthet Dent 1988;60:443-7. 9. Wolf DM, Powers JM, O’Keefe KL. Bond strength of composite to porcelain treated with new porcelain repair agents. Dent Mater 1992;8:158-61. 10. Aida M, Hayakawa T, Mizukawa K. Adhesion of composite to porcelain with various surface conditions. J Prosthet Dent 1995;73:464-70. 11. Matsumura H, Kato H, Atsuta M. Shear bond strength to feldspathic porcelain of two luting cements in combination with three surface treatments. J Prosthet Dent 1997;78:511-7. 12. Sorensen JA, Kang SK, Avera SP. Porcelain-composite interface microleakage with various porcelain surface treatments. Dent Mater 1991;7:118-23. 13. Tylka DF, Stewart G. Comparison of acidulated phosphate fluoride gel and hydrofluoric acid etchants for porcelain-composite repair. J Prosthet Dent 1994;72:121-7. 14. Roulet JF, So ¨ derholm KJ, Longmate J. Effects of treatment and storage conditions on ceramic/composite bond strength. J Dent Res 1995;74: 381-7. 15. al Edris A, al Jabr A, Cooley RL, Barghi N. SEM evaluation of etch patterns by three etchants on three porcelains. J Prosthet Dent 1990;64:734-9. 16. Derand P, Derand T. Bond strength of luting cements to zirconium oxide ceramics. Int J Prosthodont 2000;13:131-5. ¨ zcan M, Alkumru H, Gemalmaz D. The effect of surface treatment on 17. O the shear bond strength of luting cement to a glass-infiltrated alumina ceramic. Int J Prosthodont 2001;14:335-9. 18. Bertolotti RL, Lacy AM, Watanabe LG. Adhesive monomers for porcelain repair. Int J Prosthodont 1989;2:483-9. 19. Llobell A, Nicholls JI, Kois JC, Daly CH. Fatigue life of porcelain repair systems. Int J Prosthodont 1992;5:205-13. ¨ zcan M, Pfeiffer P, Nergiz I. A brief history and current status of metal20. O and ceramic-surface conditioning concepts for resin bonding in dentistry. Quintessence Int 1998;29:713-24.

21. Peutzfeldt A, Asmussen E. Silicoating: evaluation of a new method of bonding composite resin to metal. Scand J Dent Res 1988;96:171-6. 22. Madani M, Chu FC, McDonald AV, Smales RJ. Effects of surface treatments on shear bond strengths between a resin cement and an alumina core. J Prosthet Dent 2000;83:644-7. 23. Blixt M, Adamczak E, Linden LA, Oden A, Arvidson K. Bonding to densely sintered alumina surfaces: effect of sandblasting and silica coating on shear bond strength of luting cements. Int J Prosthodont 2000;13:221-6. 24. Latta M, Barkmeier WW. Approaches for intraoral repair of ceramic restorations. Compendium 2000;21:635-29, 642-4; quiz 646. Reprint requests to: DR MUTLU OZCAN UNIVERSITAIR DOCENT ORAL HEALTH INSTITUTE FACULTY OF MEDICAL SCIENCES UNIVERSITY OF GRONINGEN ANTONIUS DEUSINGLAAN 1 9713 AV GRONINGEN THE NETHERLANDS FAX: (31)50-363-2696 E-MAIL: [email protected] Copyright © 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 ϩ 0 10/1/127897

doi:10.1067/mpr.2002.127897

Bound volumes available to subscribers Bound volumes of The Journal of Prosthetic Dentistry are available to subscribers (only) for the issues from the publisher at a cost of $($international) for Vol. . Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-654-2452 or 407-345-4000. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.

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