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How To Bond Zirconia: The APC Concept: Continuing Education 1
How To Bond Zirconia: The APC Concept: Continuing Education 1
BONDING ZIRCONIA
LEARNING OBJECTIVES
Abstract: Zirconia has become one of the most popular materials in dentistry. đƫ%/1//ƫ0$!ƫ !2!(+,)!*0ƫ
+"ƫ*!3ƫ$%#$ġ0.*/(1!*0ƫ
New high-translucent zirconia ceramics have favorable optical properties and 6%.+*%ƫ!.)%/
can be applied as monolithic full-contour restorations in various clinical indica- đƫ4,(%*ƫ0$!ƫ%),+.0*!ƫ
tions for posterior and anterior teeth. However, having reliable cementation +"ƫ.!/%*ƫ+* %*#ƫ+*ƫ
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protocols is fundamental for clinical success of indirect ceramic dental restora- !.)%ƫ.!/0+.0%+*/
tions, including those made from zirconia materials. Resin bonding supports đƫ!/.%!ƫ0$!ƫ,.+,!.ƫ
+* %*#ƫ,.+0++(/ƫ"+.ƫ
ceramic restorations and is necessary for onlays, laminate veneers, and resin-
6%.+*%ƫ.!/0+.0%+*/
bonded fixed dental prostheses. The APC zirconia-bonding concept is based
on decades of research on how to achieve high and long-term durable bond čƫ.ċƫ(06ƫ$/ƫ.!!%2! ƫ
$+*+..%ƫ".+)ƫ+!(ƫ%+.!ƫ
strengths to high-strength ceramics. It includes three practical steps: (A) air- * ƫ1..5ƫ+.%0'!ƫ!*0(Čƫ* ƫ
.!/!.$ƫ/1,,+.0ƫ".+)ƫă
ƫċƫ
particle abrasion, (P) zirconia primer, and (C) adhesive composite resin. This
/ċƫ35!.ƫ%/ƫƫ,% ƫ+*/1(0*0ƫ"+.ƫ
1..5ƫ+.%0'!ċ
article discusses the history and development of high-translucent zirconia and
explains the necessity for proper cementation. The rationale and science behind a simplified zirconia-bond-
ing concept is explained and illustrated with a clinical case presentation.
S
everal new materials and technologies have had a tre- the zirconia framework.2,3 Consequently, researchers conducting
mendous impact on clinical dentistry and helped rev- newer clinical studies could not find differences in the long-term
olutionize traditional restorative treatment concepts. performance between PFZ and porcelain-fused-to-metal (PFM)
Zirconium-dioxide (ZrO2, zirconia) ceramics have crowns.3-5 Still, widespread concerns about veneer-porcelain chip-
fundamentally changed clinical applications and the ping and the more technique-sensitive firing and handling of zirco-
range of indications for all-ceramic restorations, from single-tooth nia persisted, and ultimately led to the development of CAD/CAM-
restoration to full-mouth implant-supported rehabilitations.1-3 fabricated monolithic full-contour zirconia restorations that did
The first CAD/CAM-fabricated zirconia (more accurately not require application of a veneering porcelain.
termed yttria-stabilized zirconium dioxide, or yttria-stabilized Numerous products have entered the market. In the meantime,
tetragonal zirconia polycrystals [Y-TZP]) coping was introduced millions of full-contour zirconia restorations have been inserted
in the late 1990s to provide a strong and more esthetic framework and their use has proven to be an efficient and cost-effective alter-
for a porcelain-fused-to-zirconia (PFZ) restoration. Nobel Procera® native to layered indirect restorations due the CAD/CAM fabrica-
Zirconia (Nobel Biocare, Nobelbiocare.com) was the first popular tion process. Translucency of this second generation of zirconia
product, followed by LavaTM Zirconia (3M ESPE, 3mespe.com) in materials was slightly improved compared with first-generation
the early 2000s. The demand for PFZ crowns increased rapidly materials while retaining similar flexural strength values. However,
due their esthetic properties and the zirconia core material of more customization and individual shading had to be achieved through
than 1000 MPa in high flexural strength. Early studies and clinical soaking or applying liquid dye to the milled green-stage or presin-
experiences, however, indicated high incidences of chipping and tered material and external staining after sintering.
fractures, especially within the veneering porcelain.1 Better under- To simplify the process, some manufacturers have introduced pre-
standing of the material enabled the development of veneering por- shaded zirconia blanks, some of them with multiple layers of slightly
celains that better matched the physical and thermal properties of different shades between dentin and enamel areas to better simulate
the appearance of natural teeth. Restorations made with multilay- significant influence on the clinical success of all-ceramic restora-
ered zirconia can still be modified and customized to a certain degree tions.8,9 In general, adhesive bonding with composite resins and ad-
with external stains or simply polished to the desired luster. equate pretreatment of the abutment tooth and ceramic bonding
The latest generation of zirconia materials has a significantly higher surface have the ability to support ceramic restorations, improve
degree of translucency, providing greatly improved esthetics. The use retention, reduce microleakage, and increase fracture resistance of
of multilayer high-translucent zirconia materials, in particular, pro- the restoration and abutment tooth.10 The clinical procedures and
vides a great range of esthetic possibilities, specifically for anterior surface pretreatment steps differ, depending on the composition
teeth.6 The higher translucency is achieved by slight changes of the and mechanical properties of the ceramic substrate.8 The two ma-
yttria (Y2O3) content (5 mol% or more instead of the conventional 3 jor categories of ceramic materials are silica based (ie, feldspathic,
mol%), which is used to stabilize the tetragonal zirconia phase, caus- leucite-reinforced, lithium disilicate) and non-silica–based high-
ing a higher amount of cubic phase particles. Cubic zirconia offers strength ceramics, which include alumina and zirconia. The quality
significantly greater light transmission but lower physical strength. and durability of the bond between the composite resin and ceramic
High-translucent zirconia has flexural strength values between 550 are key for clinical success.8-10 They typically depend on the surface
MPa and 800 MPa, depending on the degree of translucency; the topography of the substrate, surface energy, and chemical interac-
higher the translucency, the lower the flexural strength.7 Its specific tion with the resin.8 As with any adhesive interactions, contamina-
properties make it a viable material alternative for the esthetic zone. If tion of the bonding surfaces has adverse effects on bond strengths.
bonded properly, it can be even used for laminate veneers and onlays. Hydrofluoric-acid etching, followed by application of a silane-
coupling agent, is recommended for glassy-matrix ceramics.11
Ceramic Bonding Hydrofluoric-acid etching selectively dissolves the glass matrix
Ceramic materials are brittle and cannot undergo plastic deforma- and produces a porous, irregular surface of increased wettabil-
tion as metal alloys do. Therefore, their modulus of elasticity and ity. Application of a silane-coupling agent on the etched ceramic
behavior under functional stress is different from metals. The crys- surface increases adhesion through mechanical interlocking and
talline structure allows for crack propagation when the surface is coupling the silica (silicon oxides) to the organic matrix of resin
damaged or external forces become excessive. Therefore, the type materials by means of siloxane bonds.11 The intaglio surfaces of
of luting agent and technique for permanent cementation have a silica-based ceramic restorations should not be treated with blunt
Fig 1. Fig 2.
Fig 3. Fig 4.
pretreatment seems more important than actual surface roughen- coated with a silica-based ceramic or silica-containing particles.21
ing, especially with its ability to effectively decontaminate the bond-
ing surfaces.22 As the effects of air-particle abrasion on the flexural APC-Step C
strength of zirconia have been discussed extensively, most existing Dual- or self-cure composites (APC-Step C) should be used to ensure
studies indicate that particularly small particles actually provide adequate polymerization/conversion beneath the zirconia restoration,
a strengthening effect.23 which reduces light transmission.8 However, high-translucent zirconia
transmits enough light that the shade of the cement or composite-resin
APC-Step P luting agent influences the final appearance of such restorations. It is,
The subsequent step includes application of a special ceramic therefore, highly recommended to verify the anticipated appearance
primer (APC-Step P), which typically contains special adhesive with try-in pastes and select the most adequate cement shade based
phosphate monomers, onto the zirconia bonding surfaces.24,25 The on the individual situation and shade of the abutment tooth.
monomer MDP, which is also used in some dentin bonding agents The APC zirconia-bonding concept is not limited to teeth and
and cements, has been shown to be particularly effective to bond also applied in the laboratory, for example for implant reconstruc-
to metal oxides. Such primers may also increase bonding abilities tions that include cemented zirconia components.
of other cements, such as resin-modified glass ionomers, to zirco- For new high-translucent zirconia products with lower flexural
nia.26 However, it is highly suggested to stay within recommended strength, proper bonding is even more important and may be nec-
company product lines for bonding agents, primers, and cements, essary for restorations fabricated at minimum thickness. It is man-
and to not interchange products from different manufacturers, datory for bonded restorations such as resin-bonded fixed dental
which may have similar names, but likely different chemical com- prostheses,14 laminate veneers, and inlays/onlays,27,28 all of which
positions that may not be compatible with each other. Some clini- can be fabricated from zirconia with excellent longevity, as long as
cians may be confused due to the fact that some special zirconia they are bonded correctly.14
primers also contain silanes, which make them universally appli- The described APC zirconia-bonding concept is not new but rather
cable to various materials, including silica-based ceramics. But a culmination of research studies spanning 2 decades to identify ef-
remember that silanes have no contributing effect to long-term fective, yet clinically feasible, bonding protocols. Findings from re-
bond strengths to metal-oxide–based ceramics unless they are cent systematic literature reviews, which evaluated the data of more
Fig 8. Fig 9.
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1. The increased translucency of recent high-translucent zirconia 6. The preferred surface treatment when bonding to silica-based
materials is due to: ceramics is:
ƫ ċƫ ƫ$%#$!.ƫ)+1*0ƫ+"ƫ1%ġ,$/!ƫ,.0%(!/ċ ƫ ċƫ $5 .+ý1+.%ġ% ƫ!0$%*#ƫ* ƫ/%(*!ƫ,,(%0%+*ċ
ƫ ċƫ ƫ(+3!.ƫ)+1*0ƫ+"ƫ1%ġ,$/!ƫ,.0%(!/ċ ƫ ċƫ #.%* %*#ƫ3%0$ƫ %)+* ƫ1.ƫ* ƫ/%(*!ƫ,,(%0%+*ċ
ƫ ċƫ *!3ƫ/0%*%*#ƫ0!$*%-1!/ċ ƫ ċƫ %.ġ,.0%(!ƫ./%+*ƫ3%0$+10ƫ*5ƫ+0$!.ƫ/1."!ƫ0.!0)!*0ċ
ƫ ċƫ !4!//%2!ƫ/%*0!.%*#ċ ƫ ċƫ /%(*!ƫ,,(%0%+*ƫ3%0$+10ƫ*5ƫ+0$!.ƫ/1."!ƫ0.!0)!*0ċƫ
2. High-translucent zirconia has flexural strength values between: 7. The preferred surface treatment when bonding to zirconia is:
ƫ ċƫ āĀĀƫ
ƫ* ƫĂąĀƫ
ċ ƫ ċƫ $5 .+ý1+.%ġ% ƫ!0$%*#ƫ* ƫ/%(*!ƫ,,(%0%+*ċ
ƫ ċƫ ĂąĀƫ
ƫ* ƫĆĆĀƫ
ċ ƫ ċƫ #.%* %*#ƫ3%0$ƫ %)+* ƫ1.ƫ* ƫ/%(*!ƫ,,(%0%+*ċ
ƫ ċƫ ĆĆĀƫ
ƫ* ƫĉĀĀƫ
ċ ƫ ċƫ %.ġ,.0%(!ƫ./%+*ƫ3%0$ƫ(1)%*ƫ* ƫ6%.+*%ƫ
ƫ ċƫ āĀĀĀƫ
ƫ* ƫāĆĀĀƫ
ċ ƫ ƫ ,.%)!.ƫ,,(%0%+*ċ
ƫ ċƫ /%(*!ƫ,,(%0%+*ƫ3%0$+10ƫ*5ƫ+0$!.ƫ/1."!ƫ0.!0)!*0ċƫ
3. As a general rule for zirconia:
ƫ ċƫ 0$!ƫ$%#$!.ƫ0$!ƫ0.*/(1!*5Čƫ0$!ƫ$%#$!.ƫ0$!ƫý!41.(ƫ/0.!*#0$ċ 8. Air-particle abrasion of zirconia bonding surfaces:
ƫ ċƫ 0$!ƫ$%#$!.ƫ0$!ƫ0.*/(1!*5Čƫ0$!ƫ(+3!.ƫ0$!ƫý!41.(ƫ/0.!*#0$ċƫ ƫ ċƫ /$+1( ƫ*!2!.ƫ!ƫ +*!ċ
ƫ ċƫ 0$!ƫ(+3!.ƫ0$!ƫ0.*/(1!*5Čƫ0$!ƫ(+3!.ƫ0$!ƫý!41.(ƫ/0.!*#0$ċƫ ƫ ċƫ %/ƫ*+0ƫ*!!//.5ċ
ƫ ċƫ 0$!ƫ !#.!!ƫ+"ƫ0.*/(1!*5ƫ%/ƫ*+0ƫ+..!(0! ƫ3%0$ƫ ƫ ċƫ )1/0ƫ!ƫ +*!ƫ3%0$ƫ(.#!ƫ(1)%*ƫ,.0%(!/ƫĨ0ƫ(!/0ƫāāĀƫμ)ĩƫ0ƫƫ
ƫ ƫ ý!41.(ƫ/0.!*#0$ċ ƫ ƫ $%#$ƫ,.!//1.!ƫ+"ƫ+2!ƫąƫ.ċƫ
ƫ ċƫ *ƫ/1þ%!*0(5ƫ!ƫ +*!ƫ3%0$ƫ/)((ƫ(1)%*ƫ,.0%(!/ƫĨĆĀƫμ)ƫƫ
4. Ceramic materials are brittle and: ƫ ƫ 0+ƫćĀƫμ)ĩƫ0ƫ(+3ƫ,.!//1.!ƫ!(+3ƫĂƫ.ċƫ
ƫ ċƫ 1* !.#+ƫ,(/0%ƫ !"+.)0%+*ƫ/ƫ)!0(ƫ((+5/ƫ +ċ
ƫ ċƫ !$2!ƫ(%'!ƫ)!0(/ƫ1* !.ƫ"1*0%+*(ƫ/0.!//ċ 9. Special zirconia primers:
ƫ ċƫ $2!ƫ0$!ƫ/)!ƫ)+ 1(1/ƫ+"ƫ!(/0%%05ƫ/ƫ)!0(/ċƫ ƫ ċƫ 05,%((5ƫ+*0%*ƫ $!/%2!ƫ,$+/,$0!ƫ)+*+)!./Čƫ/1$ƫ/ƫƫ
ƫ ċƫ **+0ƫ1* !.#+ƫ,(/0%ƫ !"+.)0%+*ƫ/ƫ)!0(ƫ((+5/ƫ +ċ ƫ ƫ
Čƫ3$%$ƫ+* ƫ0+ƫ)!0(ƫ+4% !/ċ
ƫ ċƫ .!ƫ*+0ƫ*!!//.5ċ
5. Adhesive bonding of ceramic restorations: ƫ ċƫ (35/ƫ+)!ƫ%*ƫ %û!.!*0ƫ/$ !/ƫ0+ƫ)0$ƫ0$!ƫ &!*0ƫ
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