Lab Tribune Middle East & Africa No.5, 2023
Wanted: Research on 3D-printed zirconia restorations / A chairside CAD/CAM lithium disilicate block in the hands of the dental technician: Giving that extra touch
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[1] =>
DTMEA_No.5. Vol.13_LT.indd
PUBLISHED IN DUBAI
www.dental-tribune.me
Vol. 13, No. 5
Wanted: Research on 3D-printed
zirconia restorations
By Anisha Hall Hoppe, Dental
Tribune International
JAZAN, Saudi Arabia: Zirconia-based restorations, renowned for
their durability and aesthetics resembling natural teeth, have gained popularity over the past 20 years and are
increasingly being produced using
CAD/CAM. A recent systematic review and meta-analysis comparing
milled versus 3D-printed zirconia
prostheses has found continual gaps
in the research, including biases, and
potential under–representation of
the performance capabilities of
3D-printed restorations. A complete
lack of clinical studies on the efficacy
of 3D–printed zirconia crowns and
fixed dental prostheses (FDPs) also
highlights how far research into zirconia crown fabrication has yet to go.
Zirconia, dubbed “ceramic steel”
for its robustness, is a preferred
choice for various dental restorations
owing to its high strength and biocompatibility, among other attributes. The introduction of CAD/CAM
technologies has enhanced the precision of manufacture of zirconia restorations by minimising human error.
There are two main fabrication methods: subtractive (milling) and additive
(3D printing). Each technique has its
advantages. Milling is cost-effective
and less sensitive to minor design imperfections, while printing offers
more design flexibility and efficiency
in intricate structures. While 3D printing of dental restorations is nascent,
studies comparing the effectiveness
of milled versus printed zirconia are
scarce.
The present review was conducted in an effort to bridge this
knowledge gap by seeking to determine whether the performance of
zirconia crowns and FDPs produced
by both methods compares favourably with that of conventionally produced ones. The review included various in vitro studies, necessary in lieu
of any available clinical studies on
3D-printed zirconia restorations, and
the results are intended to guide clinicians in selecting the best method
There is great need for research when it comes to zirconia restorations, regardless of the manufacturing process.
(Image: jit1115/Freepik)
AD
for creating crowns and FDPs. The included articles were published from
2004 to November 2022 and reported on the placement of over
1,500 zirconia restorations, predominantly in the posterior regions. The
studies involved a variety of clinical
designs, and most patients were followed for over a year.
Clinically, zirconia crowns and
FDPs showed impressive biological
and physical properties, with few reported issues. The meta-analysis revealed that, regardless of variables
like age, glazing/staining, location
and marginal integrity, the pooled
survival rate of these crowns and
FDPs was consistently high, at 100%.
In the context of in vitro studies comparing 3D-printed and milled zirconia crowns and FDPs, findings suggested that both methods offered
comparable accuracy, adaptability
and strength, positioning 3D printing
as a viable option for clinical use.
The main biological outcome
observed across the board was
bleeding on probing. Technical issues, such as crown fractures, were
noted, one study recording a survival
rate of 91.5%. Proper polishing was
found to reduce the chance of crown
fracture. Other key findings in the review were that patients with bruxism
should be treated with zirconia
crowns and FDPs with great caution
and adjustments might be needed
after crown placement owing to occlusal issues or pain. The average
preservation of marginal integrity
was high, but varied depending on
the study. Zirconia was found to
cause wear on opposing teeth, but
less so than other ceramics.
There is limited literature on zirconia’s aesthetic aspects, especially
concerning colour. The review faced
challenges like technique variability
and limited patient sample size. Conclusively, zirconia crowns and FDPs,
whether 3D-printed or milled, are
promising but require more extensive research, especially long-term
studies, to validate their benefits over
traditionally produced prostheses.
Although in some cases the literature
suggests that milled crowns and
FDPs are superior to 3D-printed
ones, there were no identified direct
comparisons performed in any studies. The lack of research into
3D-printed crowns and FDPs may
have contributed to this result.
The study, titled “Clinical effectiveness of 3D-milled and 3D-printed
zirconia prosthesis—a systematic review and meta-analysis”, was published on 27 August 2023 in Biomimetics.
[2] =>
DTMEA_No.5. Vol.13_LT.indd
LAB TRIBUNE
B2
Lab Tribune Middle East & Africa Edition | 05/2023
A chairside CAD/CAM lithium disilicate
block in the hands of the dental
technician: Giving that extra touch
tion. Compared with zirconia, the uncompromised versatility (anterior or
posterior region, monolithic or veneered), the high aesthetics and the
possibility of adhesive luting are convincing in the field of single-tooth
restorations. The ceramic, which is
based on the proven high-density
micronisation technology, has already conquered the hearts of many
dental technicians as a pressing material (GC Initial LiSi Press). Now the
success story is being continued with
a CAD/CAM block.
By Christian von Bukowski,
Germany
CAD/CAM silicate ceramic blocks
for the production of single-tooth
restorations such as crowns and inlays have been available on the market for a long time. These are mainly
targeted at dental practices, but dental technicians also benefit from the
potential of modern CAD/CAM silicate ceramics in the form of blocks.
GC Initial LiSi Block is a fully crystallised lithium disilicate ceramic for the
production of single-tooth restorations that, from an aesthetic point
of view, are uncompromising in many
respects, even to the critical gaze of
a dental technician.
For decades, we as dental technicians have dealt intensively with the
imitation of natural teeth. It is one of
our unique selling points and our
personal merit to create ceramic restorations with artistry that imitate the
tooth almost completely in shape
and light optics. For some years now,
monolithic production with its many
advantages has been the focus of interest and often gives rise to a dichotomy. On one hand, we favour
the manual layering of ceramics.
With great attention to detail and the
subtleties of layering technology, we
can create highly aesthetic restorations that are difficult to beat in
terms of individuality. On the other
hand, monolithic production is economically attractive. Whether using
pressing or CAD/CAM manufacturing, monolithic production is in competition with the layering technique,
especially concerning posterior res-
Fig. 1: Fully crystallised lithium disilicate ceramic GC Initial LiSi Block for
single-tooth restorations in the dental laboratory.
torations. Silicate ceramics in particular have high aesthetic potential.
This is also of interest to dental practices, particularly because CAD/CAM
blocks made of silicate ceramics
promise the economical production
of aesthetic crowns, inlays, etc. In
order to be able to stake a claim on
the production of single-tooth restorations in this changed environment,
dental technicians should ascertain
the potential of modern CAD/CAM
materials in block form and, if useful,
integrate them into their everyday
work.
A charming alternative to
layering
Owing to economical, time-saving production, the laboratory remains competitive in the field of single-tooth restorations. The icing on
02
the cake is that dental technicians
know how to achieve that bit extra
from a restoration through their particular expertise, attention to detail
and craftsmanship than is possible in
the vast majority of dental practices;
in any case, this should be our conciliatory claim as dental technicians because there are alternatives to the
layering technique for the production of ceramic restorations. However, the high bar set by the layering
technique still applies. The monolithic restoration should satisfy the
critical eye of the dental technician in
all respects. One material that meets
this requirement is GC Initial LiSi
Block. Especially in the posterior region, a fully crystallised lithium disilicate ceramic such as GC Initial LiSi
Block (Fig. 1) represents a charming
alternative to conventional produc-
03
A short excursion into materials science
Lithium disilicate ceramics belong to the group of reinforced silicate ceramics. The starting product is
glass, in which corresponding crystals (reinforcing particles such as leucite or lithium silicate crystals) grow
through controlled nucleation and
crystallisation.1 Therefore, such ceramics are called reinforced silicate
ceramics. GC Initial LiSi Block is an
optimised or modified variant of the
classic lithium disilicate ceramic. The
fully crystallised lithium disilicate
block possesses its final and optimal
physical properties without the need
for ring and is thus stable and fast to
mill. GC Initial LiSi Block offers the
same biaxial strength (of 408 MPa)
with or without ring.
The ceramic distinguishes itself
from the other materials of its class
by its significantly refined crystals.
Owing to HDM technology, the crystals in the glass matrix are smaller
and more evenly and more densely
distributed. According to the manufacturer, this leads to a higher wear
resistance, precisely fitting margins
and highly aesthetic results, which we
can confirm from our everyday laboratory work.
With regard to our targeted perfection, a monolithic crown made of
GC Initial LiSi Block can be given an
extra touch of naturalness with the
GC Initial IQ ONE SQIN concept—a
paintable colour and micro-layering
ceramic system. It consists of three
materials that are perfectly adapted
for use together, ensuring an efficient and aesthetically convincing finalisation of monolithic and buccally
micro-reduced restorations. Colour
and fluorescence are added with GC
Initial IQ Lustre Pastes ONE. These
also serve as the connection ring for
the SQIN ceramics, which enable optimal creation of the desired tooth
shape with texture integration.
Owing to their autoglaze effect, no
additional glaze ring is needed. Both
of these can be mixed with GC Initial
Spectrum Stains, fine powder stains
for infinite individualisation options.
Depending on each case, you
can use the elements of the system
that you need.
Insight into the dental laboratory
As test users, we put GC Initial
LiSi Block through its paces from a
dental technician’s perspective. We
wanted to know how well the ceramic
works without any and with individualisation. Processing and accuracy of
fit were also put to the test.
04
Fig. 2: The exact accuracy of fit and the homogeneous surface were impressive. Figs. 3 & 4: The crown looked very natural and required no reworking.
preparation
& scan
...only polished
05
cad
06
07
Fig. 5: The crown milled from GC Initial LiSi Block and finished without additional ring. Fig. 6: Preparing the model for crowns #25, 34 and 35. Fig. 7: CAD construction of the fully anatomical individual crowns
[3] =>
DTMEA_No.5. Vol.13_LT.indd
LAB TRIBUNE
B3
Lab Tribune Middle East & Africa Edition | 05/2023
08
09
Figs. 8 & 9: The accuracy of t and the warm colour effect in this pure state were convincing.
10
Fig. 10: Our polishing set for lithium disilicate crowns
GC Initial LiSi Block in its pure
version
For the first case, GC Initial LiSi
Block was tested in its pure version:
mill, polish, place. As usual, model
preparation, construction and nesting took place (see the second case
for a more detailed description).
After separating the restoration from
the sprue, we only slightly reworked
the crown and polished it according
to our protocol (Figs. 2–4). The accuracy of t and the smooth edges were
just as convincing as the beautiful colour effect. The surfaces after milling
were homogeneous and had a semigloss sheen. The excellent polishability was also impressive; in just a few
steps, a high gloss was achieved. The
result was appealing (Fig. 5), and the
procedure was an adequate alterna-
11
tive to other procedures but with a
significantly reduced amount of
work. For patient work, however, we
always prefer some icing on the
cake—the painting or micro-layering
technique—to achieve the most
from the crown. In that case, we
would have characterised the crown
a little darker.
GC Initial LiSi Block with an extra
touch
In this case, three premolars were
produced. The preparation of the
virtual model as well as the CAD took
place as usual in the software. In just
a few simple steps, the fully anatomical crowns were created and ready
for import into the CAM software
(Figs. 6 & 7). High- and low-translucency blocks (in Shade A2) were
12
tested. In addition, we had set different quality levels via the milling strategy (M1 CAD/CAM unit, Zirkonzahn;
heavy wet, zirconia) to check the accuracy of t. When calculating the
milling paths, the quality levels can
be adjusted depending on the milling time. The software displays the
required milling tools and informs
about the required milling time.
The milling resulted in smooth
and precisely fitting edges. The surfaces were also wonderfully silky. The
first inspection of the model showed
the extraordinarily good fit. There
was no obvious difference between
the milling quality levels. Only minor
reworking—proximal fine adjustment, occlusal correction and homogenisation of the surfaces—was necessary after separation from the
sprue (Figs. 8 & 9). Commercial abrasives can be used for this. We prefer
the following combination: silicone
polishers, polishing stones, buffs,
bristles, ceramic fibre points and a
good polishing paste (Fig. 10). An
appealing result with natural opalescence and an inconspicuous beautiful colour effect was already apparent (Fig. 11). Because of the homogeneous, fine surface, the texture
looked natural.
But we wanted that extra touch
that distinguishes a crown created by
a dental technician. With GC Initial IQ
Lustre Pastes ONE, the crowns were
individualised with a touch of 3D colours and glaze pastes (Fig. 12). GC
Initial IQ Lustre Pastes ONE are a
mixture of refined glass-ceramic particles and can therefore be easily applied and purposefully positioned.
Depending on taste or need, subtle
or intensive effects can be achieved.
After the firing, we were inspired by
the crowns’ natural fluorescence and
their effect on the tooth-coloured
stumps (Fig. 13). This simple and economical approach produced a result
that could match that of a conventionally manufactured crown. Owing
to the inherent gloss of the GC Initial
IQ Lustre Pastes ONE glaze pastes, a
shiny surface was obtained (Figs. 14–
16). This particular case did not require detailed surface texture. However, when more texture is necessary,
like for a central incisor of a young
patient, SQIN ceramics can be added
on top. The GC Initial Spectrum
Stains complete the range of possibilities.
Findings
Since no crystallisation firing had
to be executed, the production time
was significantly shorter. The fast
milling process resulted in smooth
and precisely fitting edges. Even
after the characterisation or glaze firing, the accuracy of fit of the margins
and the surface texture were retained. We were also convinced by
the natural opalescence and the vividly warm colour effect without loss
of value. An excellent gloss level
could be achieved in just a few minutes by polishing. In addition, simple,
effective individualisation was possible with the paintable colour and
form ceramic concept GC Initial IQ
ONE SQIN. If necessary, impressive
characterisation can be achieved
with a very thin layer of no more than
0.1–0.6mm. GC Initial LiSi Block will
complement the portfolio of materials in our laboratory. Especially when
work needs to move quickly or if a
high level of cost-efficiency is required, ceramics are not only an adequate alternative but also the material of choice in certain cases for single-tooth restorations. There is always our desire as dental technicians
to achieve more for every restoration, and this is possible using GC
Initial LiSi Block, offering natural
beauty, simplicity and versatility.
Reference
1 Rosentritt M, Kieschnick A,
Hahnel S, Stawarczyk B. Materials
Science Compendium Dental Ceramics, 2019.
Editorial note: This article was published in CAD/CAM—international magazine of dental laboratories vol. 13, issue
2/2022.
Christian von
Bukowski
became a dental technician in
1990 at the Staatliche Berufsschule
München-Land, a vocational school in
Munich in Germany, after three years of
intensive training in a commercial dental laboratory. Thereafter, he attended
the master school for dental technicians in Halle (Saale) in Germany from
1994 to 1996, where he obtained his
master’s degree. Since 2006, he has
been running his own laboratory in Unterschleißheim near Munich.
13
Fig. 11: The crowns on the model before individualisation by means of the painting technique. Fig. 12: Ready-to-use GC Initial IQ Lustre Pastes ONE for a 3D colour effect. Fig. 13: The crowns after the characterisation ring on tooth-coloured dies.
14
15
16
Figs. 14–16: Harmonious naturalness and a radiantly warm liveliness from the inside out, achieved in a very short production time. (All images courtesy of © Christian von Bukowski, MDT
[4] =>
DTMEA_No.5. Vol.13_LT.indd
SAVETHEDATE
15-16 NOVEMBER 2024
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