DR. DENNIS HARTLIEB
Porcelain Margin Repair
Porcelain Margin Repair
Reality check – it happens to all of us. There are going to be situations where, despite our best efforts, after years of service, there will be breakdown and staining at the margin of our porcelain restorations. I think most of us would agree that replacement of the restoration is likely the most ideal treatment, however there may be times due to patient finances, time issues or life situations, that replacement of the restoration is not the most ideal treatment. If I’m able to isolate the margin appropriately, and if the restoration is in good standing otherwise, a resin repair of the porcelain margin can be a good restoration to manage the initial or early failure of the restorative margin.
Now, before beginning the repair of the margin I believe that it is imperative to inform the patient that repairing the margin with composite is not as ideal as replacing the restoration. I inform the patient that I only expect the repair to last about 3-5 years, with likely marginal breakdown at the porcelain/composite interface to blame. I explain to the patient that they will likely see staining at the composite margin and slight separation of the composite from the porcelain over time. But for many patients, repairing and maintaining the restoration is a better alternative than replacing the restoration.
The following photographs are the documentation of a margin repair that I performed recently on a patient of my practice. I did not place the porcelain restorations, but the margins, outside of the facial stained margin, were in good order and the patient was otherwise pleased with the esthetics of the restoration. I hope the documented steps are helpful if you decide to perform this technique on your patients.
Now, before beginning the repair of the margin I believe that it is imperative to inform the patient that repairing the margin with composite is not as ideal as replacing the restoration. I inform the patient that I only expect the repair to last about 3-5 years, with likely marginal breakdown at the porcelain/composite interface to blame. I explain to the patient that they will likely see staining at the composite margin and slight separation of the composite from the porcelain over time. But for many patients, repairing and maintaining the restoration is a better alternative than replacing the restoration.
The following photographs are the documentation of a margin repair that I performed recently on a patient of my practice. I did not place the porcelain restorations, but the margins, outside of the facial stained margin, were in good order and the patient was otherwise pleased with the esthetics of the restoration. I hope the documented steps are helpful if you decide to perform this technique on your patients.
Read also: Composite Pit Repair
Isolation
If you are able to secure a rubber dam, then that would be most ideal. Otherwise, as in this case, place retraction cord to gain separation from the gingival tissue to fully expose the faulty margin.
Preparation
I like using the microdiamond burs from Brassler – in this case I’m using the 830M.31.012 bur. I like this pear-shaped bur because I can get into the defect while minimally impacting the porcelain. Following the stain removal, I place a bevel as if I were doing a Class V composite on tooth structure. The bevel should be similar in length to the defect, deeper at the porcelain-tooth interface, and if just fades away along the facial. No chamfers or deep penetrating margins along the facial porcelain. Microetching with 50 micron aluminum oxide can help with the enhancement of the bond of the composite to porcelain.
Continued Isolation
We need to use hydrofluoric acid to etch the porcelain, which means that we need to protect the exposed tooth structure and gum tissue. I use a liquid rubber dam material (Gingiguard). The flexible resin composite is flowed onto the tooth structure to prevent the acid from seeping onto the tooth or gum tissue. I manipulate the Gingiguard with an explorer then cure for 10 seconds.
Porcelain etching
It is important to know what type of porcelain that you are etching. There are classically 3 types of porcelain that we will see when working in dentistry today: 1) feldspathic, 2) lithium disilicate (i.e. eMax (Ivoclar), LiSi (GC America)), and leucite (Empress, Ivoclar). Each of these porcelains, unfortunately, have different etching protocols.
Of course, the challenge is figuring out what kind of porcelain you’re dealing with if you haven’t done the initial restorations. Generally speaking, if you are working on a PFM or Zirconia layered crown, you are working with feldspathic porcelain. If it is a more recently placed all ceramic restoration (not zirconia), it’s likely that it is lithium disilicate.
The challenge is older all ceramic restorations – how do you know if its Empress, or say eMax. They both are etched with 5% HF, so the question is for how long. If the restoration is bright (high value), I’m thinking that it is probably an Empress restoration. Empress also isn’t as hard as eMax when prepping – it almost feels ‘softer’ when drilling. But sometimes in the end, it’s a bit of a guess.
After the requisite etching time, the hydrofluoric acid is rinsed, being careful to suction the acid off of the porcelain prior to rinsing and drying. It is important to recognize that you must use extreme care when using hydrofluoric acid in the mouth. Ideally, rubber dam isolation is used to reduce the risk of the patient exposure to HF.
- Feldspathic porcelain should be etched with 9.5% hydrofluoric acid for 3-4 minutes.
- eMax and Empress type ceramics should be etched with 5% HF. Emax should only be etched for 20 seconds, while Empress should be etched for 1 minute.
Of course, the challenge is figuring out what kind of porcelain you’re dealing with if you haven’t done the initial restorations. Generally speaking, if you are working on a PFM or Zirconia layered crown, you are working with feldspathic porcelain. If it is a more recently placed all ceramic restoration (not zirconia), it’s likely that it is lithium disilicate.
The challenge is older all ceramic restorations – how do you know if its Empress, or say eMax. They both are etched with 5% HF, so the question is for how long. If the restoration is bright (high value), I’m thinking that it is probably an Empress restoration. Empress also isn’t as hard as eMax when prepping – it almost feels ‘softer’ when drilling. But sometimes in the end, it’s a bit of a guess.
After the requisite etching time, the hydrofluoric acid is rinsed, being careful to suction the acid off of the porcelain prior to rinsing and drying. It is important to recognize that you must use extreme care when using hydrofluoric acid in the mouth. Ideally, rubber dam isolation is used to reduce the risk of the patient exposure to HF.
Silane placement
Silane is an important material to use when bonding to porcelain. Silane is a ‘coupler’ that promotes infusion of the resin into the etched porcelain. I place a layer or two of the silane on the etched porcelain and allow the silane to sit for about a minute before air drying. After the silane has been placed and evaporated, the liquid rubber dam material is removed.
Adhesion
If there is even a modest amount of enamel to bond to, then I will etch the enamel first with 37% phosphoric acid. Phosphoric acid still gives us the best bond to enamel, compared to our self-etch or universal etch adhesives.
In this case, since there is no enamel at the cervical margin, I will use a self-etch adhesive system. I’m using Clearfil SE (primer and bond) – a self-etch system with decades of clinical success. The primer is lightly scrubbed with a small microbrush onto the tooth surface for about 20 seconds, then air thinned. The second part of the system, the ‘Bond’ is applied with an artist’s brush over both the tooth surface and the etched porcelain. The bond is air thinned and light cured for 20 seconds. For more information on different etching systems, check out any of my direct resin courses on dothandson.com.
In this case, since there is no enamel at the cervical margin, I will use a self-etch adhesive system. I’m using Clearfil SE (primer and bond) – a self-etch system with decades of clinical success. The primer is lightly scrubbed with a small microbrush onto the tooth surface for about 20 seconds, then air thinned. The second part of the system, the ‘Bond’ is applied with an artist’s brush over both the tooth surface and the etched porcelain. The bond is air thinned and light cured for 20 seconds. For more information on different etching systems, check out any of my direct resin courses on dothandson.com.
Dentin Layer
As I describe in my Class V course, in shallow Class V restorations, a dentin layer may not be necessary. The dentin layer is typically used to add underlying chroma to the restoration prior to placing the enamel layer. In this case, I’m using a very thin layer of hybrid flowable composite (Renamel, Cosmedent) not so much to add chroma (the ceramic that I am matching does not have a lot of chroma in the gingival third) – but I’m using the flowable to ensure that my restorative material fills into any of the surface irregularities of the preparation. Now it is critical that I don’t overfill with my flowable – I need to save room for the enamel layer (microfill).
A secondary advantage of using the flowable is that by having that first layer placed (and cured), it is much easier to place the microfill because of the ‘stickiness’ of one composite to the other. This will help prevent ‘pull back’ of the microfill composite when I place that layer. The final advantage of using the hybrid flowable is that the hybrids are radio-opaque, whereas the microfills are not identifiable radiographically. This radiopacity issue is obviously more critical in Class II and Class III restorations, but still is nice to see when x-rays are taken. The hybrid flowable is cured for 10 seconds.
A secondary advantage of using the flowable is that by having that first layer placed (and cured), it is much easier to place the microfill because of the ‘stickiness’ of one composite to the other. This will help prevent ‘pull back’ of the microfill composite when I place that layer. The final advantage of using the hybrid flowable is that the hybrids are radio-opaque, whereas the microfills are not identifiable radiographically. This radiopacity issue is obviously more critical in Class II and Class III restorations, but still is nice to see when x-rays are taken. The hybrid flowable is cured for 10 seconds.
Enamel Layer
I am a firm believer that whenever possible, a microfill composite is used as the facial layer of our direct composite restorations. Microfills give us the best polish, and this polish maintains long term, unlike the microhybrids or nanofills. I roll the microfill (Renamel) into a small ball, place over the cervical surface, and using titanium coated instruments, blend the composite onto the tooth surface at the cervical margin and onto the etched porcelain. Care is taken to be certain that the composite is as smooth as possible before final polymerization (60 seconds).
A layer of glycerin (Oxygone, Cosmedent) is placed over the composite after 10 seconds of curing, prior to the full curing. The glycerin helps insure complete polymerization of the composite and elimination of the oxygen inhibited layer. Glycerin is water soluble and easily rinsed off after the final polymerization.
A layer of glycerin (Oxygone, Cosmedent) is placed over the composite after 10 seconds of curing, prior to the full curing. The glycerin helps insure complete polymerization of the composite and elimination of the oxygen inhibited layer. Glycerin is water soluble and easily rinsed off after the final polymerization.
Contour
Contouring can be completed with carbide burs, diamond burs or discs. I generally prefer to use discs (FlexiDiscs System) when blending composite to the etched porcelain surface. I work the discs from composite to porcelain, first using the most coarse discs with moderate pressure, but light to medium speed (~ 5000-8000 rpm on my electric handpiece)
It is critical that you do not use water spray. You will see the ‘white line’ when you first begin your contouring. When the composite is not smooth enough to the porcelain margin, composite dust settles into this interface giving us the white line. So carefully, working composite to porcelain, run your coarse disc until that white line disappears. There ya’ go – perfectly smooth margin. I’ll follow up with the medium coarse disc which will give my microfill a ‘matte’ finish.
At this point, there should be no defects in the composite surface – any pits or defects should be corrected prior to moving onto the polishing steps (see my blog on composite repairs). Along the cervical margin I’ll use a fine diamond mini bur (8392-016 Brassler), using a blunt instrument to retract the gingival tissue as I move along the cervical.
It is critical that you do not use water spray. You will see the ‘white line’ when you first begin your contouring. When the composite is not smooth enough to the porcelain margin, composite dust settles into this interface giving us the white line. So carefully, working composite to porcelain, run your coarse disc until that white line disappears. There ya’ go – perfectly smooth margin. I’ll follow up with the medium coarse disc which will give my microfill a ‘matte’ finish.
At this point, there should be no defects in the composite surface – any pits or defects should be corrected prior to moving onto the polishing steps (see my blog on composite repairs). Along the cervical margin I’ll use a fine diamond mini bur (8392-016 Brassler), using a blunt instrument to retract the gingival tissue as I move along the cervical.
Final Polish
I use a combination of rubber cups and discs for the final polish. I like using Cosmedent’s Flexicups because of their flex – they will conform to the shape of the cervical contour and allow me to bring the cups subgingival. The cups come in blue (medium coarse) and pink (fine). I use water spray when using the rubber cups to keep the tooth cool while polishing. Over the facial surface, and onto the porcelain interface, I prefer to use the polishing discs. With the Flexidisc system, the yellow and pink discs are used, being sure to flex the discs onto the composite/porcelain surface. The discs are run with increased speed and pressure.
The final step in polishing is using an aluminum oxide polishing paste (Enamelize) with a polishing disc (Flexibuff). Floss is run interproximally to ensure smooth contours.
The final step in polishing is using an aluminum oxide polishing paste (Enamelize) with a polishing disc (Flexibuff). Floss is run interproximally to ensure smooth contours.
Remove Isolation
Whether you are using a rubber dam or retraction cord, it's time to remove the isolation. Hopefully, the cord is able to be removed without significant trauma to the tissue. If the cord has been ‘bonded’ to the tooth surface, I use an anterior sickle scaler and run the scaler horizontally along the margin to release the adhesive from the cord.
Ok, that’s the technique, step-by-step. If you have any questions, please submit questions at www.dothandson.com/social.
Yours for better dentistry,
Ok, that’s the technique, step-by-step. If you have any questions, please submit questions at www.dothandson.com/social.
Yours for better dentistry,
Dennis Hartlieb, DDS, AAACD
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Meet Dr. Dennis Hartlieb
Dr. Dennis Hartlieb owns his own practice in Chicago,IL and has been teaching dentistry for over 30 years. Dr. Hartlieb is the CEO and the main instructor at Dental Online Training. He is an active member in the American Academy of Cosmetic Dentistry where he’s both an Accredited Member and Examiner for Accreditation.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Meet Dr. Angela Luek
Dr. Angela M. Lueck is a Wisconsin native and was the youngest female in her class from Marquette University in 1998. Since completing her residency she has consistently taken more than 100 hours a year of continuing education to keep current on the latest trends, techniques, and materials available in dentistry.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
Meet Clare O'Neill
Clare O’Neill is the Director of Operations at Dental Online Training and has a professional background in digital marketing. Clare has certifications in content marketing and digital advertising. Clare has expertise in social media marketing, email marketing, content marketing, website management, and project management. Clare has been using Canva for over 5 years and is a self-proclaimed Canva Queen.
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
Meet Dr. Jim Mckee
Dr. McKee is a member of the Spear Resident Faculty. He has maintained a private practice since 1984 in Downers Grove, Illinois where he treats a wide variety of cases with a focus on predictable restorative dentistry. He is a member of the American Academy of Restorative Dentistry and former president of the American Equilibration Society.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
Meet Kirk Behrendt
Kirk Behrendt is a renowned consultant and speaker in the dental industry, known for his expertise in helping dentists create better practices and better lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
Meet Dr. Melissa Seibert
Melissa Seibert is a comprehensive dentist proudly serving in the Air Force. She holds a dual faculty appointment at Uniformed Services University and Creighton Dental School. She serves on the editorial board for Inside Dentistry.
Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
Meet Olivia Wisden
Olivia Wisden is the founder & CEO of TwoLips Creative. What started as an events discovery app pivoted into a creative agency that specializes in working with startups, small businesses, and organizations who are looking for bold, impactful designs and strategies.
She has worked with dozens of brands over the years ranging from the City of Madison to product launches and beyond.
She has worked with dozens of brands over the years ranging from the City of Madison to product launches and beyond.
Meet Dr. Sofya Kats
Dr. Sofya Kats is local to Milwaukee, WI. She grew up in Bayside and attended Nicolet HS, UW-Milwaukee and Marquette University School of Dentistry. Dr. Kats is a member of the Greater Milwaukee Dental Association, Wisconsin Dental Association, American Dental Association, and The Forum Study Club (oldest Dental Study Club in the United States).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).
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Day 1 (8 - 4 pm CST)
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Erosion and wear – the why and the how
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Adding length to teeth – when is it safe
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Opening VDO to compensate for lost tooth structure – where to begin
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Records visit and key points you need to understand before you start
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The smile – the 7 strategic points to consider when evaluating the smile
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Anterior tooth shape, morphology
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Clinical case review
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Upper Putty matrix construction
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Build lingual incisal wall with putty matrix #6 - #11/ Upper anteriors
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Full contour build-up #6, #7, #8, #9, #10, #11, shape and polish/ Upper anteriors
Day 2 (8 - 2 pm CST)
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Who – which patients are candidates
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Why – explaining to patients the value of the prototype
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How – step-by-step techniques to maximize predictability, efficiency and success
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Getting to Yes: conversations with patients about esthetic and reconstructive dentistry
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The ‘Smile Preview’ – techniques to show the possibilities
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Lower Putty matrix construction
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Build lingual incisal wall with putty matrix #22 - #27 / lower anteriors
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Build-up #22 - #27, shape and polish / lower anteriors
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Build-up lower occlusal posteriors
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Demonstration of Smile Preview