Art-6-Ozcan
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RESTORATIVE DENTISTRY
INTRAORAL REPAIR OF CERAMIC CHIPPING USING
Case Reports
RESIN COMPOSITE: DESCRIPTION OF A STEPBYSTEP
TECHNIQUE
Mutlu Özcan1a , Luis Gustavo D’ Altoé Garbelotto2b , Claudia Angela Maziero Volpato2c
Division of Dental Biomaterials, Center of Dental Medicine, Clinic for Reconstructive Dentistry, University of Zürich, Zürich, Switzerland
Department of Dentistry, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
a
DDS, PhD, Professor, dr.h.c.; e-mail: mutlu.ozcan@zzm.uzh.ch; ORCIDiD: https://orcid.org/---
b
DDS, MSc, Professor; e-mail: luisgarbelotto@me.com; ORCIDiD: https://orcid.org/ ---
c
DDS, MSc, PhD, Associate Professor; e-mail: claudia.m.volpato@ufsc.br; ORCIDiD: https://orcid.org/---
ABSTRACT https://doi.org/10.25241/stomaeduj.2021.8(2).art.6
Aim This article aims to present and discuss an intra-oral repair technique for repairable ceramic fractures in
tooth- or implant-supported fixed dental prostheses.
Summary In the intra-oral repair technique, after insulation with rubber-dam and proper cleaning, a bevel
was prepared at the margins of the fractured area with a fine-grain diamond bur. Conditioning with 9.6%
hydrofluoric acid was carried out for 120 s in the bevel and in the fractured area. On the clean and dry
surface, the silane coupling agent was applied and allowed to react for one minute. Afterwards, the resin
adhesive was rubbed on the surface, allowing the restoration of the area to repair with small increments of
resin composite. The intra-oral repair was finished and polished with discs and rubber tips, and the occlusion
was adjusted.
Key learning points 1. To execute a minimally invasive approach. 2. To repair the damaged ceramic area of
a prosthesis restored in a single session. 3. To learn the meticulous order of surface conditioning, finishing
and polishing protocols.
KEYWORDS
Adhesion; Ceramics; Chipping; Intra-Oral Repair; Resin Composite.
1. INTRODUCTION Associated with this, laboratory factors, such as
the irregular thickness of the veneering ceramic,
Despite advances in digital laboratory strategies to inadequate infrastructure design, and the presence
manufacture tooth- and implant-supported fixed of defects and micro-porosities incorporated after
dental prostheses (FDP), obtaining personalized stratification, further increase the risk of failure.
esthetic results, especially in anterior areas, still
Insufficient dental preparation, inadequate occlusal
depends on traditional ceramic stratification
techniques. In these techniques, feldspar porcelain adjustment, lack of ceramic polishing after occlusal
is applied on the framework, layer by layer, using adjustment, stresses during chewing, trauma, or
powders with different colors and opacities [1]. An the presence of parafunctions also contribute to
excellent esthetic result is obtained in multi-layered the formation of cracks and their propagation until
prostheses; however, an interface is generated fracture [5,6].
between the framework and the veneering ceramic, Clinical follow-up studies report that fractures of the
representing the most fragile link of this type of veneering ceramic and the presence of dental caries
restorations [2]. Thus, chipping and fractures of the are the most frequent failures in metal-ceramic FDPs
veneering ceramic are frequently observed in such [7]. The fracture of the veneering ceramic is also
FDPs [3]. This is due to the lower strength of porcelain
observed in prostheses with zirconia frameworks,
compared to the material used in the framework
(metal or zirconia); the presence of residual stress with failure rates ranging between 6 to 15%, after 3
resulting from the incompatibility of the thermal years [8]. These prostheses have a higher percentage
expansion coefficients (CET) between the materials, of failures than traditional metal-ceramic FDPs,
and the tension resulting from the cooling that which present chipping or fracture rate of about 4%
occurs after ceramic sintering [3,4]. over a 10-year period of clinical follow-up [9].
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Özcan M, Garbelotto LGD, Volpato CAM. Intra-oral repair of ceramic chipping using resin composite: a step-by-step technique. Stoma Edu J.
2021;8(2):126-131.
Received: May 16, 2021 Revised: June 08, 2021; Accepted: June 22, 2021; Published: June 24, 2021
*Corresponding author: Professor Mutlu Özcan, DDS, PhD, Division of Dental Biomaterials, Center of Dental Medicine, Clinic for Reconstructive
Dentistry, University of Zürich, Plattenstrasse 11, CH-8032, Zürich, Switzerland
Tel.+41-44-634-5600, Fax:+41-44-634-4305, e-mail: mutlu.ozcan@zzm.uzh.ch
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
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Regarding failures, different behaviors are also In this technique, the fractured area is restored with
Case Reports
observed in implant-supported FDPs. In these resin composite materials.
prostheses, the masticatory load is about 8 to 10 For the intra-oral repair to be successful, it is essential
times greater than in the teeth, due to the lack of to confirm the clinical and radiographic quality of
proprioceptive receptors in the periodontal ligament the prosthesis before the intervention along with
[10]. The implant/prosthetic component has an assessing the type and size of the failure. A direct
elasticity module much higher than the natural repair with resin composite can only be made
tooth [11], which results in a higher concentration if the prosthesis has good marginal adaptation
of stresses and an increase in failures. Fractures and and adequate esthetics [14]. The patient must be
chipping of the veneering ceramic were observed informed about the advantages and disadvantages
in about 12.4% of implant-supported FDPs, after 5.7 of the intra-oral repair technique before the
years [12]. procedure.
Regardless of the prosthesis present in the oral cavity, The fracture that occurs in the veneering ceramic
fractures and chipping result in great discomfort for may or may not expose the framework. Thus,
the patient, who seeks care to solve this problem different materials may be present after the fracture,
and esthetic compromise, especially when the guiding the adhesive protocol that should be used
fracture occurs in the anterior area. The replacement during the repair technique (Table 1). Regarding
the size, the failures can be small, moderate or large
of these restorations must be carefully evaluated by
[15]. Minor failures, such as discreet chipping of
the clinician, since it involves additional costs, as well
the veneering ceramic, can be solved by finishing
as increase in working time [5]. If the prosthesis has
with discs and polishing with rubber tips. Intra-oral
good marginal adaptation and adequate esthetic
repairs made with resin composite resin can solve
quality, the fractured area can be repaired without
small and medium failures that present esthetic
the need of removal, as long as the failure has not
and functional implications. On the other hand,
compromised the structural, functional and esthetic major failures, which involve areas of proximal and
integrity of the prosthesis [13]. occlusal contacts, are usually resolved with indirect
repairs made in the laboratory or by replacing the
2. INTRA-ORAL REPAIR USING RESIN COMPOSITE prosthesis [15].
The durability of intra-oral repairs made with resin
The technique of resin composite intra-oral repair is composite depends of the factors such as the
a minimally invasive approach that aims to restore location of the failure, adhesive potential of the
the damaged area of a prosthesis, avoiding its substrate, previous treatment of the surface to
removal and subsequent replacement [6]. If the be repaired, quality of the adhesive protocol, and
clinician chooses to replace the prosthesis, she/he direction and magnitude of the forces applied in the
must consider that removing the prosthesis with resin composite repair [6]. In order to improve the
burs can lead to greater wear of the dental tissue, adhesive potential of different ceramic substrates,
in addition to being a more expensive and complex surface treatments such as conditioning with
procedure. On the other hand, intra-oral repair is hydrofluoric acid (HF), air-abrasion with aluminum
a quick and economical procedure, which can be oxide particles or tribo-chemical treatment followed
done in a single clinical session, without the need by the application of a silane coupling agent can be
for additional clinical steps or laboratory costs [14]. used [16,17].
Table 1. Surface conditioning protocols for different substrates present in intra-oral fractured areas.
Substrate present after fracture Adhesive protocol
Tooth (enamel or dentin) Etch with 37% phosphoric acid (30 seconds for enamel and 15 seconds for dentin), rinse for
the same time and dry with oil-free air, taking care not to dehydrate the dentin. Apply a coat of
primer on the dentin with a disposable brush, followed by applying the adhesive resin to the
enamel and dentin.
Metal Air-abrasion using alumina particles coated with silica or silica only (particle size range: 30 to
50 microns, blasting pressure: 2.5 bar), for approximately five seconds in circling motion, and
rotating the nozzle at a distance of approximately 10 mm. Apply a coat of primer and allow the
solvent to volatilize for 1 minute. Then, apply adhesive resin agent and photo-polymerize for 20
seconds before starting the intraoral repair.
Feldspathic porcelain and glass- Clean the area with fluoride-free prophylaxy paste or pumice, followed by etching with hydro-
ceramics (leucite and lithium fluoric acid 5 to 9.6% for 2 min (feldspathic porcelain), 1 min (leucite) or 20 s (lithium disilicate).
disilicate) Rinse for the same duration and dry with oil-free air. Apply one coat of the silane coupling
agent and allow the solvent to volatilize for 1 minute. After, apply adhesive resin agent and
photo-polymerize for 20 seconds before starting the intraoral repair.
Oxide ceramics (zirconia) Air-abrasion using alumina particles coated with silica or silica only (particle size range: 30 to
50 microns, blasting pressure: 2.5 bar), for approximately five seconds in circling motion, and
rotating the nozzle at a distance of approximately 10 mm. Apply a coat of primer and allow the
solvent to volatilize for 1 minute. Then, apply adhesive resin agent and photo-polymerize for 20
seconds before starting the intraoral repair present after fracture.
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3. DESCRIPTION OF THE TECHNIQUE properly treated before conditioning the porcelain.
Case Reports In exposed metal frameworks, air-abrasion the
The intra-oral repair technique is indicated for surface with alumina particles coated with silica
dental- and implant-supported fixed prostheses or silica only (particle size range: 30 to 50 microns,
that have small to moderate failures. In addition, blasting pressure: 2.5 bar), for approximately five
these prostheses should have good clinical seconds in a circling motion, and rotating the nozzle
and radiographic adaptation, in addition to an at a distance of approximately 10 mm.
acceptable esthetic appearance [12,14]. The steps In zirconia infrastructures, air-abrasion or tribo-
to make an intra-oral repair in resin composite are chemical treat-ment with silica deposition must
described below: also be made before the application of the silane
1. After identifying the need to make an intra-oral coupling agent. The lithium disilicate infrastructures
repair (Fig. 1), match the color of the resin composite respond well to conditioning with hydrofluoric acid
that will be used during the clinical protocol for 20 seconds, allowing the action of the silane
(Fig. 2). A shade guide or a small increment of photo- agent and bonding with the adhesive resin.
polymerized resin composite over the area can be 6. After conditioning, wash the area with abundant
used for shade selection. water for three minutes. Neutralizing agents can
2. Insulation of the working site with rubber-dam be applied on the area for one minute to neutralize
to protect the soft tissue and adjacent teeth from the action of the acid. The area is washed and dried
the damaging effects of hydrofluoric acid (HF), and again.
to keep the area dry during adhesive procedures, 7. Apply silane coupling agent on the dried area
avoiding contamination with saliva. with a clean disposable brush (Fig. 8). The silane
3. Make a prophylaxis of the area to be repaired with is maintained for one minute and the solvent is
brushes and prophylactic paste without fluoride to removed with oil-free air.
remove the contaminants present on the ceramic 8. Rub the adhesive resin over the area with a
surface (Fig. 3). clean disposable brush for 20 seconds (Fig. 9). The
4. Prepare a bevel in the remaining ceramic with adhesive resin excess is removed by aspiration and
a fine-grain diamond bur (Fig. 4). Use abundant photo-polymerized for 20 s.
irrigation to avoid heating of the ceramic, preventing 9. Afterwards, the intra-oral repair is performed with
the propagation of cracks. The bevel will allow a the resin composite previously selected, through
smoother transition between the ceramic and the small increments. Place each increment in the area
resin composite, in addition to increasing the area with a spatula, placing them in position (Fig. 10).
available for adhesion of the material (Fig. 5). Each increment is photo-polymerized for 20 seconds
5. The remaining ceramic surface that will not be (Fig. 11).
repaired, must be protected by glycerine gel or a If the metal infrastructure is exposed, mask the
polyfluoroethylene tape. Air-abrasion of the area metal with opaque resin before making the repair
can also be made before acid conditioning, for 10 and photo-polymerize for 40 seconds from each
seconds, in order to obtain a more effective cleaning direction.
(Fig. 6). 10. The repair is finished with discs and polished with
If adhesion is made on feldspathic porcelain, 9.6% rubber tips and polishing paste (Figs. 12 and 13).
hydrofluoric acid should be applied to the bevel and Afterwards, check the patient's occlusion so that the
fractured area for two minutes (Fig. 7). If the metal repaired area is not overloaded during the function
or ceramic infrastructure is exposed, it must be (Fig. 14).
Figure 1. Chipping of the veneering ceramic in ceramic Figure 2. Color matching of resin composite with shade guide
implant-supported crown. (VITA Classical, VITA Zahnfabrik, Germany).
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Case Reports
Figure 3. Rubber-dam and cleaning of the area with Figure 4. Preparation of the bevel with a fine-grain
prophylaxy paste. diamond bur (KG Sorensen, FF Series, Brazil).
Figure 5. Completed bevel.. Figure 6. Air-abrasion with aluminum oxide particles for
effective cleaning of the area. Before air-abrasion, the
remaining ceramic was protected with glycerin gel and the
adjacent teeth with protective tape.
Figure 7. Conditioning the fractured area and bevel with 9.6% Figure 8. Application of the silane coupling agent (RelyX,
hydrofluoric acid gel (Pulpdent, USA) for two minutes. 3M ESPE, USA) over the conditioned area with a clean
disposable brush.
Figure 9. The adhesive resin bonding (Adper Scothbond Figure 10. A small increment of resin composite (Filtek Z-350
Multi-Purpose, 3M ESPE, USA) is rubbed on the area with a clean XT, 3M ESPE, USA) is placed in the area.
disposable brush, and the excess adhesive is removed with
disposable suction.
Figure 11. Each increment is photo-polymerized for 20 Figure 12. The intra-oral repair is finished with discs.
seconds.
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Case Reports
Figure 13. The intra-oral repair is polished with Figure 14. Final view of intra-orally repaired ceramic using resin
rubber tips. composite.
4 . DISCUSSION should be used when employing the intra-oral repair
technique.
If intra-oral repair on a prosthesis is indicated upon In contrast, zirconia is an acid-resistant ceramic,
fracture or chipping, the esthetic and functional which does not respond well to acid conditioning
problems caused by these failures can be more as it does not have silica in its microstructure.
quickly resolved, without the need for removal Additionally, zirconia is an inert substrate with low
and subsequent replacement of the prosthesis surface energy and wettability [17]. To obtain a
[12,14,15]. This procedure reduces the cost and strong and reliable adhesion to zirconia surfaces, it
time of treatment, and also provides immediate is essential to employ methods based on the use of
comfort to the patient, who has his problem air-borne particle abrasion with alumina particles or
solved in a single clinical session [14]. However, the physicochemical methods use silica-coated alumina
success and longevity of resin composite intra-oral particles (tribochemical silica coating) followed
repair depends on compliance with the adhesive by silanization. After the application of silane, the
protocol, which will be defined according to the zirconia surface can be chemically activated by
type of ceramic exposed after the failure [13,17,18]. using functional-monomer containing adhesive
In this technique, adhesion is essential to maintain promoters (such as 10-methacryloyloxydecyldihy-
the resin composite repair strongly attached to drogenphosphate - MDP) [17,18].
the damaged surface, without the need to create Other precautions that must be taken during the
additional mechanical retentions on the ceramic intra-oral repair technique refer to the execution of a
surface, which would certainly result in increased bevel on the margins of the fractured area; a refined
failure and possible crack propagation. finishing and polishing, and a careful occlusal
The surfaces of ceramic materials currently available adjustment [14]. A larger area of ceramic is exposed
on the market exhibit different adhesive behavior after making the bevel, with more silica particles,
based on their composition and crystalline structure increasing the surface available for adhesion. In
[16-18]. Feldspathic porcelains and vitreous cera- addition, especially in failures that occur in esthetic
mics such as leucite and lithium disilicate are areas, a smoother transition between the two
acid-sensitive ceramics, responding well to classic different materials (resin composite and ceramic)
adhesive techniques that employ hydrofluoric acid can be achieved. The finishing and polishing of the
and the application of the silane coupling agent. The repair guarantees greater patient comfort, as well
more glass phase is present in the microstructure of as reducing the possibility of future pigmentation,
these ceramics, the greater the surface roughness which would imply its replacement [14,15]. The
produced by acid conditioning, improving the occlusal adjustment after the intra-oral repair is
bond to the resin adhesive [16]. The use of silane decisive for its success, since often premature
coupling agent allows the union of silicon dioxide contacts and occlusal interference are responsible
(SiO2) present in the ceramic surface with the for the failure and, if they are not solved, the intra-
resin adhesive [13]. These agents are inorganic- oral repair will certainly fail.
organic hybrid bifunctional molecules, capable of
creating a siloxane network with the hydroxyl (OH) 5. CONCLUSIONS
of the silica present on the ceramic surface, and
copolymerizing with the adhesive agent, which will - The intra-oral repair is a minimally invasive
bond with the restorative material. However, the use technique that increases the survival of prostheses
of hydrofluoric acid must be performed carefully, that have suffered chipping of the veneering
as it can result in damage to soft tissues, like burns, porcelain.
due to their corrosive potential [14,15]. The severity - Resin composite is the material of choice for this
of the burn is dependent upon the concentration of technique as it can be used for direct failure repair.
the acid and the duration of the exposure [19]. In this - The damaged ceramic area of a prosthesis can
way, proper control of conditioning time, adequate be restored in a single session, with an adequate
absolute isolation, as well as a good suction system, aesthetic and functional solution.
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- The prosthesis can be kept functional in the ACKNOWLEDGMENTS
Case Reports
None
mouth, without the need for replacement and costly
replacements. AUTHOR'S CONTRIBUTION
- The meticulous execution of an adequate adhesive
protocol will guarantee the success and longevity of MÖ: concept, design of the study and critical review, revising the
article critically for important intellectual content, final approval
the repair made. of the version to be submitted.
LG: acquisition of data, drafting the article.
CONFLICT OF INTEREST CV: acquisition of data, drafting the article, final approval of the
The authors declare no conflict of interest. version to be submitted.
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Stoma Edu J. 2021;8(2):126-132 pISSN 2360-2406; eISSN 2502-0285 131
Intra-oral repair of ceramic chipping
www.stomaeduj.com
Case Reports Mutlu ÖZCAN
DDS, PhD, Professor, dr.h.c.
Division of Dental Biomaterials
Center of Dental Medicine
Clinic for Reconstructive Dentistry
University of Zürich
Zürich, Switzerland
CV
Professor Mutlu Özcan is the Head of the Division of Dental Biomaterials at the University of Zurich, Center for Oral
Medicine, Clinic for Reconstructive Dentistry in Switzerland. She has authored more than 700 clinical and scientific
peer-reviewed manuscripts. She is Fellow in Dental Surgery of the Royal College of Physicians and Surgeons of
Glasgow, FDS RCPS (Glasgow) and recipient of the “2018 IADR Distinguished Scientist Award”.
Questions
1. Intra-oral repairs with resin composite are indicated for:
a. Small to moderate failures in the veneering ceramic of bilayer prostheses;
b. Large failures in occlusal areas;
c. Large failures in proximal areas;
d. Failures that compromised the integrity of bilayer prostheses.
2. For the success of the intra-oral repair technique, it is important to consider:
a. The prosthesis must be removed to facilitate the adhesive protocol;
b. A chamfer should be performed on the margins of the fractured area;
c. The ceramic around the fractured area must be removed until the infrastructure is completely exposed;
d. A bevel should be made on the margins of the fractured area.
3. To make the intra-oral repair technique, it is important to use:
a. Relative insulation made with cotton rolls;
b. Clean and disposable brushes for applying silane agent silane and resin adhesive;
c. Coarse grain bur to prepare the fractured area;
d. Retraction cords for isolation.
4. The most suitable treatments for the exposed surface after the ceramic fracture are:
a. Conditioning with 9.6% hydrofluoric acid for metal surfaces;
b. Conditioning with 9.6% hydrofluoric acid for zirconia surfaces;
c. Conditioning with 9.6% hydrofluoric acid for feldspathic porcelain surfaces;
d. Tribo-chemical treatment for feldspathic porcelain surfaces.
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