Efficiency of Er, Cr:YSGG Laser in Laminate Veneers Debonding

on Two Ceramic Materials and Resin Cements.

THE AIM :
The purpose of this study was to evaluate the efficacy of wavelength transmitted laser peels in
the family of dental lasers of the erbium type (using a turbo handpiece) and its effect
on the topography of the selected ceramic surface, as well as the atomic compistion of debonded
ceramic veneers.

MATERIALS AND METHODS:

In this study, a total of 80 ceramic specimens were used. They were divided into two groups (n=
40/group) according to ceramic material used, Group (A) lithium disilicate (IPS Emax), Group
(B) Feldspathic porcelain. (VITA MARK II). Each group was further subdivided into two
subgroups according to the cement curing mode (n= 20/subgroup): Subgroup (L) Light cured
resin cement, Subgroup (D) Dual cured resin cement, Er,Cr:YSGG (turbo handpiece) was used
on all subgroups. Scanning electron microscope were used to evaluate surface tomography and
EDAX atomic percentage in order to compare their longevity and success rate. Data were
analyzed statistically.

RESULTS:
Scan electron microscope images revealed: The IPS Emax showed the typical lithium disilicate
crystals embedded in a glass matrix, rod shaped that are interlocked and haphazardly organized.
whileThe VITA MARK II showed a microstructure based on aluminum, potassium and sodium
based silicate with grains of about 4 µm, very porous material, described as honeycombed
surface.
EDAX atomic percentages: the initial baseline results are consistent with what the manufacturer
has said. The second examination carried out following laser irradiation with these parameters
for debonding revealed variances in chemical composition generally compared to the reference
groups, and even variations were discovered by altering the manner of cement curing mode.

CONCLUSION:
The Er,Cr:YSGG laser could be an effective and useful tool in debonding of lithium disilicate
and feldspathic ceramic veneers.
KEYWORDS: laser debonding, ceramic veneers, shear bond strength, rebonding.

1
INTRODUCTION
The Smile was found to be one of the first traits that get recognized during interpersonal
interactions, where a beautiful smile was valued as high self-esteem. Dentistry has changed
dramatically over the past decades, from just the meaning of treating the pain of dental disease to
accomplishing the optimal standards of beauty. With all the influences of the media that people
get exposed to frequently nowadays, dental esthetics has become a challenge[1, 2].
There are different esthetic restorative materials available nowadays in dentistry, which may be
used directly and indirectly. The most popular restorative material is the porcelain laminate
veneers {Aguiar, 2010 #45}which are known to have various advantages for their ability to bond
to the tooth structure, low occlusal wear of opposing teeth, and on top of that its esthetic
characterization especially when done with layering technique[3].
The microstructure of ceramics determines the optical and mechanical properties of the
restoration. As the glass content increases, this gives superior esthetics but low mechanical
properties, on the other hand when the fillers increase the mechanical properties also increases
showing less translucency, To combine both strength and esthetic properties, a layering
technique was used by using a high strength core veneered with translucent porcelain, monolithic
restorations fabricated by CAD/CAM in case of Feldspathic porcelain and lithium disilicate or
monolithic lithium disilicate fabricated by heat pressed technology have been suggested[4].
Materials frequently used for laminate veneers include Emax and Feldspathic porcelain those
types of veneers offers numerous benefits and features, Emax and Feldspathic veneers are
primarily made by CADCAM technology, which makes them highly durable. Moreover, these
come in thin layers, and this prevents the need for drilling teeth. This is the most impressive
feature of this type of veneer since teeth are preserved, unlike with conventional veneers[5].
However some localized failures could happen such as discoloration, microleakage, ditching at
the margins, or simple fracture, so it needs to be repaired or replaced, new technique of porcelain
laminate veneer debonding was recently developed by using Er:YAG laser (Erbium‐doped:
yttrium aluminum garnet) which was inspired by its applications on the orthodontic ceramic
brackets that started in the 1990s[6, 7].
Therefore, it seems worthwhile to investigate the surface properties and shear bond strength of
CAD/CAM blocks (VITA MARK II and IPS E-max) debonded by Er,Cr:YSGG laser resembling
porcelain laminate veneers to provide recommendations for the best clinical procedure to be
easily rebonded.

2
MATERIALS AND METHODS :
1.Materials:
In this study, the selected wave length was applied on two ceramics. The surface topography was
analyzed at base line and after debonding, also the Shear bond strength was measured after
rebonding of lased veneers.
Table (1): The ceramic blocks in the study.

Chemical
Materials Clinical Lot
Code Classification Manufacturer content
tested Indications number
(wt. %)

56–64%
SiO2,
20-23% Veneers, inlays,
Feldspathic
VITA VITA Zahnfabrik, Al2O3, onlays, anterior
VIT glass-matrix 63050
Mark II Germany and posterior
ceramic 6–9% Na2O, crowns.
6–8%
K2O

Veneers, inlays,
58–80% onlays, anterior
SiO2, and posterior
crowns,
Lithium disilicate 11–19%
anterior and
IPS based Ivoclar Vivadent Li2O,
MAX posterior X12057
e.max CAD glass-matrix AG, Liechtenstein
0–13% K2O, implant
ceramic
abutments,
0–8% ZrO2
three-unit
0–5% Al2O3 bridges up to
premolars.

Table (2) Mechanical properties of IPS e.max lithium disilicate

Property Unit of measure Value

Flexural strength MPa 360 ± 60

Chemical solubility µg/cm2 40 ± 10

3
 Expansion Coefficient 500ºC 10-6K-1 10.45 ± 0.4

Table (3): Mechanical properties of Vita Mark II.

Property Unit of measure Value

Flexural strength MPa 154 ± 15

Young’s Modulus GPa 63.0 ± 0.5

Expansion Coefficient 500ºC 10-6K-1 9.4 ± 0.1

Table (4): Resin-based luting agents used in the study.

Luting agent Organic phase Inorganic phase Lot no.

4036103
TEGDMA, BisGMA,
Dual-polymerizing Silanized ceramic
dimethacrylate functionalized 4006490
(RelyX ultimate clicker) and silica particles
polymer, triphenyl antimony
( syringe)

8714TR
Light-polymerizing dimethacrylate functionalized Silanized ceramic
(RelyX Veneer) polymer, triphenyl antimony and silica particles
(ref)

4
2) Methodology:
Specimen grouping and study design:
In this study, a total of 80 ceramic specimens were used.
Divided into two groups (n= 40/group) according to ceramic material used into:
 Group (A) lithium disilicate (IPS Emax)
 Group (B) Feldspathic porcelain. (VITA MARK II)
Each group was further subdivided into two subgroups according to the cement curing mode (n=
20/subgroup):
 Subgroup (L) Light cured resin cement
 Subgroup (D) Dual cured resin cement

 Preparation of the ceramic samples:

Using a low speed, high precision diamond saw , the specified lithium disilicate and Vita Mark II
Ceramic blocks were sliced to dimensions of 10×10 mm and thickness of 0.7 mm. The slices
were cutted using an integrated coolant delivery system that flooded the samples from both sides
of the blade while tracking blade movement. The 0.7mm thick blade moved linearly, providing a
constant feed rate cutting of 14.7 mm per minute at 2500 rpm in 50 rpm increments.then Furnace
EP3010 programat, Ivoclar was used to crystallize the ceramic discs.

Table (6): Parameters used in the crystallization of ceramic discs.

Standb Closin Heatin Holdin Holdin Max Vacuu Vacuu Long

y temp g time g Rate g g temp Tem m On m Off time
(B) (s) Time (T) p. (V1) (V2) coolin
(C°) (mm:s (t) (H) (°C) (°C) (°C) g (L)
s) (°C/ (Min.) (°C) (°C)
min)

403 06:00 90 00:10- 830– 917 550 830– 710

07:00 85083 850
0-850

5
  Fabrication of acrylic blocks:
A special mold was prepared for each bovine tooth, the ice cube mold was used to be filled with
cold-cure acrylic resin; color-coded for ease of differentiation between groups. Vaseline was
applied on the molds before cold cure acrylic resin was poured to act as a separating medium
then cold cure acrylic resin was poured in the molds and before complete setting the teeth were
fixed in the cold cure acrylic resin. Further finishing was done.
 Teeth Preparation and bonding procedures:
Freshly extracted bovine teeth stored in Saline, Labial surfaces of the teeth were initially
prepared by placing depth orientation grooves (0.3 mm) in-depth, and the labial surface was
flattened by a customized paralleling device assembly for preparation standardization. Then
etched with phosphoric acid 37% (gel) for 30 seconds then rinsed with air-water jet for 30
seconds. The bonding agent was applied and activated for 15 seconds then light-cured according
to manufacture instructions.the Ceramic samples were etched by HF acid 9.5% for 20 seconds
then rinsed with air and water spray and silinated according to manufacture instructions.
The teeth are stored in Saline for the preservation of the teeth without any effect on its grapheme
and also removal of any debris. Ceramic discs were bonded on freshly extracted bovine teeth
directly after treatment to mimic the intraoral situation with 50 (N) perpendicular load using a
dental surveyor was placed on the external surface of the veneer after cement application for 30
seconds and light-activated for 40 seconds LED curing light with an 11-mm-diameter tip
positioned 1.0 mm from the veneer surface.
After the cementation procedure, the specimens were stored in distilled water at 37 °C for 24 h to
mimic the intraoral situation.
 Laser debonding:

Water Lase IPLUS Er;Cr:YSGG (Biolase, USA) applied laser beam of wavelength 2780 nm
using the following settings for each group, The turbo handpiece is positioned perpendicular to
the veneer surface at a distance verified by a custom made positioner for standardization of
energy density. except the specimens of subdivision (i) was demolished once subjected to the
shear bond strength test, hence these subdivisions were crucial and mentioned as control group

Operation Mode Free Running Pulse

Handpiece turbo(MX7)

Repetition rate 20 Hz

Power 4.5 W

Pulse duration (60µs) H mode

Air 60%

Water 80%

6
 Non-Contact mode 5mm away

Table (7): WaterLase parameters for debonding procedures

 Scanning Electron Microscope Evaluation:

After laser debonding procedures were applied, random samples for each group of ceramic were
taken to examine surface tomography and evaluate atomic composition ( EDAX) using a
scanning electron microscope with magnification 10,000 X and 20,000X. The debonded ceramic
discs was first mounted on aluminum stubs and sputted with a gold layer using sputter coater and
then evaluated.

7
RESULTS:
Statistical analysis:

Numerical data were explored for normality by checking the distribution of data and using tests
of normality (Kolmogorov-Smirnov and Shapiro-Wilk tests). EDAX data showed non-normal
(non-parametric) distribution , Non-parametric data were presented as median and range values.

Scan Electron Microscope Evaluation:

The SEM images revealed:
 The IPS Emax CAD showed the typical lithium disilicate crystals embedded in a glass
matrix, rod shaped that are interlocked and haphazardly organized (green arrow indicates
remnants of resin cement).
 The VITA MARK II showed a microstructure based on aluminum, potassium and
sodium-based silicate with grains of approximately 4 µm, porous material, described as
honeycombed surface (green arrow indicates remnants of resin cement).

(10,000X) (20,000x)

Figure (1): SEM IPS Emax CAD evaluation at baseline.

8
 (10,000X) (20,000X)

Figure (2): SEM VITA MARK II evaluation at baseline.

(10,000X) (20,000X)

Figure (3): IPS Emax CAD cemented by Light cure resin cement evaluation after laser
debonding procedures.

(10,000X) (20,000X)

Figure (4): IPS Emax CAD cemented by Dual cure resin cement evaluation after laser
debonding procedures.

9
 (10,000X) (20,000x)

Figure (5): VITA MARK II cemented by Light cure resin cement evaluation after laser
debonding procedures.

(10,000X) (20,000x)

Figure (6): VITA MARK II cemented by Dual cure resin cement evaluation after laser
debonding procedures.

EDAX results (Atomic %)

The scan electron microscope analysis for the atomic percentage of various elements was
performed twice for both materials, once before bonding and was designated as the control
group, and the second time for both VITA MARKII and IPS E.max after the ceramic discs had
been debonded by the Er, Cr: YSGG Laser using the same parameters in all groups. The results
revealed that:

Carbon: there was a statistically significant difference between Carbon atomic % values of
different groups (P-value = 0.023, Effect size = 0.814). Pair-wise comparisons between the
groups revealed that there was no statistically significant difference between IPS E.max
cemented by dual cure resin and VITA MARK II cemented by light cure resin groups; both
showed the statistically significantly highest mean Carbon atomic %. There was no statistically
significant difference between IPS E.max cemented by light cure resin and VITA MARK II
cemented by dual cure resin groups; both showed the statistically significantly lowest mean
Carbon atomic %. Carbon was not found in IPS E.max control and VITA MARK II control
groups.

10
Oxygen: there was a statistically significant difference between Oxygen atomic % values of
different groups (P-value = 0.007, Effect size = 0.914). Pair-wise comparisons between the
groups revealed that IPS E.max control group showed the statistically significantly highest mean
Oxygen atomic %. There was no statistically significant difference between IPS E.max cemented
by light cure resin and VITA MARK II control groups; both showed statistically significantly
lower mean Oxygen atomic %. IPS E.max cemented by dual cure resin showed statistically
significantly lower mean value. There was no statistically significant difference between VITA
MARK II cemented by light cure resin and VITA MARK II cemented by dual cure resin groups;
both showed the statistically significantly lowest mean Oxygen atomic %.
Aluminum: there was a statistically significant difference between Aluminum atomic % values
of different groups (P-value = 0.007, Effect size = 0.927). Pair-wise comparisons between the
groups revealed that VITA MARK II control showed the statistically significantly highest mean
Aluminum atomic %. VITA MARK II cemented by dual cure resin group showed statistically
significantly lower mean value followed by VITA MARK II cemented by light cure resin group.
There was no statistically significant difference between IPS E.max control group and IPS E.max
cemented by light cure resin groups; both showed statistically significantly lower mean
Aluminum atomic %. IPS E.max cemented by dual cure resin showed the statistically
significantly lowest mean Aluminum atomic %.
Silica: there was a statistically significant difference between Silica atomic % values of different
groups (P-value = 0.007, Effect size = 0.901). Pair-wise comparisons between the groups
revealed that IPS E.max control group showed the statistically significantly highest mean Silica
atomic %. There was no statistically significant difference between IPS E.max cemented by light
cure resin, IPS E.max cemented by dual cure resin and VITA MARK II control groups; all
showed statistically significantly lower mean Silica atomic %. There was no statistically
significant difference between VITA MARK II cemented by light cure resin and VITA MARK II
cemented by dual cure resin; both showed the statistically significantly lowest mean Silica
atomic %.
Phosphorus: there was a statistically significant difference between Phosphorus atomic %
values of different groups (P-value = 0.016, Effect size =0.821). Pair-wise comparisons between
the groups revealed that there was no statistically significant difference between IPS E.max
control group and IPS E.max cemented by light cure resin groups; both showed the statistically
significantly highest mean Phosphorus atomic %. IPS E.max cemented by dual cure resin
showed statistically significantly lower mean value. There was no statistically significant
difference between VITA MARK II cemented by light cure resin and VITA MARK II cemented
by dual cure resin group; both showed the statistically significantly lowest mean Phosphorus
atomic %. Phosphorus was not found in VITA MARK II control group.
Fluoride: there was a statistically significant difference between Fluoride atomic % values of
different groups (P-value = 0.016, Effect size = 0.923). Pair-wise comparisons between the
groups revealed that VITA MARK II control group showed the statistically significantly highest

11
mean Fluoride atomic %. There was no statistically significant difference between VITA MARK
II cemented by light cure resin and VITA MARK II cemented by dual cure resin groups; both
showed statistically significantly lower mean Fluoride atomic %. IPS E.max cemented by dual
cure resin group showed the statistically significantly lowest Fluoride atomic %. Fluoride was
not found in IPS E.max control and IPS E.max cemented by light cure resin groups.
Sodium: there was a statistically significant difference between Sodium atomic % values of
different groups (P-value = 0.009, Effect size = 0.950). Pair-wise comparisons between the
groups revealed that VITA MARK II control groups showed the statistically significantly highest
mean Sodium atomic %. There was no statistically significant difference between VITA MARK
II cemented by light cure resin and VITA MARK II cemented by dual cure resin groups; both
showed statistically significantly lower mean Sodium atomic %. There was no statistically
significant difference between IPS E.max cemented by light cure resin group and IPS E.max
cemented by dual cure resin groups; both showed the statistically significantly lowest mean
Sodium atomic %. Sodium was not found in IPS E.max control group.
Potassium: there was a statistically significant difference between Potassium atomic % values of
different groups (P-value = 0.009, Effect size = 0.950). Pair-wise comparisons between the
groups revealed that VITA MARK II control groups showed the statistically significantly highest
mean Potassium atomic %. There was no statistically significant difference between VITA
MARK II cemented by light cure resin and VITA MARK II cemented by dual cure resin groups;
both showed statistically significantly lower mean Potassium atomic %. There was no
statistically significant difference between IPS E.max cemented by light cure resin and IPS
E.max cemented by dual cure resin groups ; both showed the statistically significantly lowest
mean Potassium atomic %. Potassium was not found in IPS E.max control group.
Calcium: there was a statistically significant difference between Calcium atomic % values of
different groups (P-value = 0.020, Effect size = 0.855). Pair-wise comparisons between the
groups revealed that IPS E.max cemented by dual cure resin group showed the statistically
significantly highest mean Calcium atomic %. VITA MARK II control group showed
statistically significantly lower Calcium atomic %. There was no statistically significant
difference between IPS E.max cemented by light cure resin and VITA MARK II cemented by
light cure resin groups; both showed the statistically significantly lowest Calcium atomic %.
Calcium was not found in IPS E.max control and VITA MARK II cemented by dual cure resin
groups.

12
Table (11): The mean, standard deviation (SD) values and results of Kruskal-Wallis test for
comparison between atomic weight % of different elements in the different groups.

e.max e.max e.max VITA VITA VITA

Control Light Dual Control Light Dual Effect
P- size
Element
value (Eta
Mean Mean Mean Mean Mean Mean squared)
(SD) (SD) (SD) (SD) (SD) (SD)

Carbon 28.7 34.4 37.6 31.9

- - 0.023* 0.814
(2.2)B (1.9)A (1.2)A (1.3)B

Oxygen 64.6 0.6 43.3 49 33.3 37.1

0.007* 0.914
(2.6)A (0.1)B (1.8)C (2)B (1.9)D (2.5)D

Aluminum 2.1 0.6 2.1 7.2 2.9 4

0.007* 0.927
(0.1)D (0.1)E (0.1)D (0.2)A (0.5)C (0.1)B

Silica 30.8 15.8 13.9 18.1 10.3 12.7

0.007* 0.901
(2.3)A (1.5)B (1.1)B (1.4)B (0.3)C (1.1)C

Phosphorus 2.6 2.8 1.5 0.7 0.7

- 0.016* 0.821
(2.3)A (0.2)A (0.1)B (0.1)C (0.2)C

Fluoride 2.2 12.6 8.8 7.8

- - 0.016* 0.923
(0.1)C (0.7)A (0.1)B (0.2)B

Sodium 0.8 0.4 7.3 3.9 4.4

- 0.009* 0.950
(0.1)C (0.1)C (0.6)A (0.1)B (0.2)B

Potassium 0.8 0.5 3.5 2 2.4

- 0.009* 0.950
(0.1)C (0.1)C (0.1)A (0.2)B (0.1)B

Calcium - 0.3 1 0.7 0.2 - 0.020* 0.855

13
 (0.1)C (0.04)A (0.1)B (0.02)C

*: Significant at P ≤ 0.05, Different superscripts in the same row indicate statistically significant difference between
groups

14
15
Figure (35): Bar chart representing mean and standard deviation
.elements in the studied groups

80
70
60
50
Atomic %

40
30
20

16
10
0
Carbon Oxygen Aluminum Silica Phosphorus Fluoride Sodium Potassium Calcium
Element
e.max Control e.max Light e.max Dual VITA Control VITA Light VITA Dual
DISCUSSION:
Porcelain veneer restorations were introduced in the early 1980s as a conservative and reliable
esthetic restoration expressing excellent clinical performance so they became one of the most
predictable, most aesthetic, and least invasive modalities of treatment[8]. Literature has
demonstrated the presence of different all-ceramic materials and systems, Among the introduced
ceramic materials is glass based feldspathic ceramics and lithium disilicate, they offers excellent
optical effects by imitating the natural enamel and dentin features, good esthetics and mechanical
properties. The material can be applied in many clinical situations such as inlays, onlays, veneers
and crowns[8].
The desire for more durable aesthetic outcomes did not confine to improve the material type only
but also the bonding protocol including the luting cement. Usually these kinds of restorations are
adhesively cemented, its bonding to tooth structure is considered efficiently strong as it depends
on micromechanical adhesion[9].However, the recent advances in materials and technology,
failure is still persist. Several factors can result in ceramic restoration failure; many of these
failures are related to the restoration fabrication, others related to bonding procedures or
practitioner experience .thus failures are liable to occurs during function and would thereby lead
to remake purpose[10].
Although the feldspathic and lithium disilicate restorations offer excellent optical effects by
imitating the natural enamel and dentin features, the removal procedure is challenging due to the
high bond strength, which is provided by using resin luting cements[11], also the removal
procedures is considered a challenging and time-consuming process and the conventional
technique still risk the underlying tooth structure due to the lack of color contrast between tooth,
adhesive resin interface and the restoration[12].
Recently, laser technology was introduced as a more comfortable and conservative technique for
ceramic veneer removal, one of its advantages is to overcome the limitations of the conventional
technique as it depends on the thermal effect of the laser in softening the luting adhesive resin
based on the absorption of water-rich substances like monomers[2]. However, limited data is
available on the bond strength of rebonded all-ceramic restorations on enamel and dentin
surfaces. The main purpose of this study was to evaluate the efficiency of Er,Cr:YSGG laser in
debonding of all-ceramic veneers and to investigate the bond strength changes of the rebonded
ones, which were removed after Er,Cr:YSGG laser application.
In this vitro study, lithium disilicate (IPS E.max) and feldspathic porcelain (Vita Mark II) were
selected, since both materials offer satisfactory level of esthetics and mechanical properties,
owing to unique microstructure. The IPS E.max composed of glass matrix infiltrated by micron-
size crystals of lithium disilicate, creating a highly filled glass matrix, while the vita mark II
consists of fluorapatite crystals in an aluminum-silicate glass .Both were demonstrated as
CAD/CAM blocks to standardize manufacture technique and defects[5].
Specimens were sectioned from LT A1 CAD/CAM blocks using Isomet. The width and height of
the specimens were 10mm× 10mm, according to block size (C14 & I14). 0.7mm specimen
thickness was standardized for all groups (n=10) as it was recommended as the thickness needed
for an all ceramic veneer[2, 13].

17
In this study Freshly extracted bovine teeth were used owing to its hardness and we can apply on
it the Er,Cr:YSGG laser at the stage of laminate veneers debonding and its considered as
substitute for human teeth in dental research[14, 15]. The ceramic discs were cemented using
resin cements; light cure resin cement(Relay x veneer )in one group due to their high esthetics,
low solubility, high bond strength, and superior mechanical properties that help reinforce the
ceramic restorations[16, 17], and for representing different curing modes the other group was
cemented using dual cure resin cement (Relay x ultimate clicker)[18, 19].
As reported in previous studies [20-22], using erbium lasers is a suitable alternative to
conventional all ceramic removal techniques. Effective laser parameters should be selected
according to the target properties: the type of bonded tooth surface, the ceramic type, and the
thickness of the restoration.Zhang et al.[23] used an Er:YAG laser with 4/4 air-water cooling, at
100 mJ energy and 30 Hz frequency to investigate the debonding time. In a study by Gurney et
al.[24] , the Er:YAG laser was used with 3.5 W and 4 W of powers, 60% air and 30% water
cooling, 25 Hz pulse rate for debonding with a laser conservatively for teeth and veneers.
Morford et al. [25] tested different Er:YAG laser parameters: 133, 217, 316, 400, and 503 mJ
energies, with a pulse repetition rate of 10 Hz for veneer debonding. Oztoprak et al. [13]selected
a laser parameter at a power of 5 W (50 Hz × 100 mJ) to evaluate the shear bond strength values
after different application durations.
The laser beam that was applied of wavelength 2780nm using the following settings for each
group Power: 4.5 W, Repetition rate: 20 Hz, Pulse duration (60µs) H mode, Air: 60%, Water:
80% and Non-Contact mode 5mm away Hand piece: turbo (MX7 fiber tip with a spot diameter
of 700 µm in focus distance) compared with the 50 Hz and 100 mJ used by Oztoprak et al[21].
It was mentioned that the distance of the laser’s head from the surface can affect the quality of
lasers. In parallel with the study of Al-balkhi et al. [2]who studied the efficiency of Er:YAG laser
in debonding of porcelain laminate veneers by contact and non-contact laser application modes,
as recommended the distance was set at 3-5 mm[2]. The laser application was made by scanning
method, perpendicular to the disc surface with circular movements, in clockwise direction, from
outer circle to the center of the cemented disc specimen, the procedure was repeated until the
strokes under the veneer sound and feel differently[18], so it was of interest to test the turbo
handpiece significance in debonding porcelain laminate veneers.
Morford et al., stated that future scanning electron microscopical investigations, which will
provide better detailed information about the surface of the enamel and even more importantly
about the veneer surface after laser debonding will be necessary to assess possible changes or
damage of the veneer due to the ablation process[25].Therefore, the laser debonding technique,
which reduces the required forces to prevent the risk of tooth and ceramic damage, was
examined in the present study by SEM images 10,000x and 20,000x magnifications.
Zheng et al., mentioned that EDX can be used to confirm the composition and distribution of the
nanoparticles through spectrum and elemental mapping[26]. Toning to Morford
recommendations compositional identification of nanoparticles using an EDX spectrometer
incorporated into a scanning electron microscopy (SEM) system was done twice at baseline and
after debonding of ceramic discs specimens using laser.

18
The results of the current study revealed that:
Scan electron microscope showed no damage or signs of ablation or ablation craters on the
porcelain laminate veneers were detected. In parallel with the study of Morford et al., he
mentioned the incident light microscopic pictures revealed that the bond between veneer and
tooth enamel is disrupted mainly at the veneer cement interface therefore leaving the majority of
the veneer clean also this observation emphasizes that laser ablation rather than thermal
softening of the cement achieves debonding of veneers[25]. Keeping in consideration the mode
of action of mentioned wavelength mainly operates by absorption of the laser energy in the
water.
And for EDAX analysis; first at the base line shows results very similar to those described by the
manufacturer. Then the second time analysis done after laser irradiation with these parameters
for debonding in general showed differences in the chemical composition compared with
baseline groups and even variations by changing the cement curing mode were detected.
We can attribute this to the organic contamination of the surface during the multi-step
preparation of the ceramic layers, some elements were already present but with difference in the
atomic percentages while others newly appeared,The differences of elemental percentages may
be explained by the structure of the ceramic, which is not homogeneous, thus resulting in
structural variations of the tested zones.
The elements newly appeared can be explained by residuals on the micro porosities created by
HF acid used before cementation, This result agrees with study of steinhauser et al[27] stated
following etching of silica-based ceramics, it has been observed that hydrofluoric acid leads to
the formation of insoluble byproducts, such as silica and fluoride salt, which may remain on
ceramic surface[27]. Finally, we can state that EDAX is considered as semi- quantitative tool
that mainly helps us to monitor the elemental determination regardless its atomic percentage.

19
CONCLUSION:

From the light of this in vitro study based on the results the following conclusions could be
drawn:

 Er,Cr:YSGG hydrokinetic laser system used for debonding a resin-bonded all-ceramic

restoration is an effective clinical application. It can be said that the application of a laser
for debonding ceramic restorations could serve as a practical and effective debonding
method that eliminates the risk of restoration fractures.
 The laser irradiation had no effect on either IPS E.max or Vita MARK II
 The presence of cement remnants after debonding demonstrated the thermal and ablative
effects induced by irradiations only in the cement layer, implying that the protocols used
may be suitable for future clinical application.
 The curing mode of resin cement have no effect on debonding efficiency of transmitted
laser of wavelengths in the Erbium Family of Dental Lasers (using turbo hand piece).

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 REFERENCES:
1. Ceci, M., et al., Discoloration of different esthetic restorative materials: A
spectrophotometric evaluation. European journal of dentistry, 2017. 11(02): p. 149-156.
2. ALBalkhi, M., E. Swed, and O. Hamadah, Efficiency of Er: YAG laser in debonding of
porcelain laminate veneers by contact and non‐contact laser application modes (in vitro
study). Journal of Esthetic and Restorative Dentistry, 2018. 30(3): p. 223-228.
3. Powers, J.M., R.L. Sakaguchi, and R.G. Craig, Craig's restorative dental materials/edited
by Ronald L. Sakaguchi, John M. Powers. 2012: Philadelphia, PA: Elsevier/Mosby.
4. Boehm, R., Temperature in human teeth due to laser heating. Pap. Am. Soc. Mech. Eng.,
1975: p. 189-19O.
5. Broome, P., Utilization of an Er, Cr: YSGG laser for the removal of all-ceramic
restorations. Practical procedures & aesthetic dentistry: PPAD, 2007. 19(1): p. 23.
6. Burkes, E.J., et al., Wet versus dry enamel ablation by Er: YAG laser. Journal of Prosthetic
Dentistry, 1992. 67(6): p. 847-851.
7. Cavalcanti, B.N., J.L. Lage-Marques, and S.M. Rode, Pulpal temperature increases with
Er: YAG laser and high-speed handpieces. The Journal of prosthetic dentistry, 2003.
90(5): p. 447-451.
8. Pătroi, D., T. Trăistaru, and S. Rădulescu, Ceramic veneers in dental esthetic treatments.
Handbook of Bioceramics and Biocomposites: Springer, Cham, 2016.
9. Soares, C.J., et al., Surface treatment protocols in the cementation process of ceramic
and laboratory‐processed composite restorations: a literature review. Journal of Esthetic
and Restorative Dentistry, 2005. 17(4): p. 224-235.
10. Calamia, J.R. and C.S. Calamia, Porcelain laminate veneers: reasons for 25 years of
success. Dental clinics of north America, 2007. 51(2): p. 399-417.
11. Kellesarian, S.V., et al., Laser‐assisted removal of all ceramic fixed dental prostheses: A
comprehensive review. Journal of esthetic and restorative dentistry, 2018. 30(3): p. 216-
222.
12. Friedman, M.J., Masters of esthetic dentistry: Porcelain veneer restorations: AS
clinician's opinion about a disturbing trend. Journal of esthetic and restorative dentistry,
2001. 13(5): p. 318.
13. Iseri, U., et al., Effect of Er: YAG laser on debonding strength of laminate veneers.
European journal of dentistry, 2014. 8(01): p. 058-062.
14. Yassen, G.H., J.A. Platt, and A.T. Hara, Bovine teeth as substitute for human teeth in
dental research: a review of literature. Journal of oral science, 2011. 53(3): p. 273-282.
15. Alikhasi, M., et al., Debonding Time and Dental Pulp Temperature With the Er, Cr: YSGG
Laser for Debonding Feldespathic and Lithium Disilicate Veneers. Journal of lasers in
medical sciences, 2019. 10(3): p. 211.
16. Kilinc, E., et al., The effect of ceramic restoration shade and thickness on the
polymerization of light-and dual-cure resin cements. Operative Dentistry, 2011. 36(6): p.
661-669.

21
17. Peixoto, R.T., et al., Light transmission through porcelain. Dental Materials, 2007. 23(11):
p. 1363-1368.
18. Karagoz-Yildirak, M. and R. Gozneli, Evaluation of rebonding strengths of leucite and
lithium disilicate veneers debonded with an Er:YAG laser. Lasers Med Sci, 2019.
19. Hofmann, N., et al., Comparison of photo‐activation versus chemical or dual‐curing of
resin‐based luting cements regarding flexural strength, modulus and surface hardness.
Journal of Oral Rehabilitation, 2001. 28(11): p. 1022-1028.
20. Nada H, E., E. Ahmed S, and A. Fayza H, Shear bond strength of ceramic laminate
veneers to enamel and enamel–dentine complex bonded with different adhesive luting
systems. Alexandria Dental Journal, 2016. 41(2): p. 131-137.
21. Oztoprak, M.O., et al., Effects of different application durations of scanning laser method
on debonding strength of laminate veneers. Lasers in medical science, 2012. 27(4): p.
713-716.
22. van As, G.A., Using the Erbium Laser to Remove Porcelain Veneers in 60 Seconds. Journal
of Cosmetic Dentistry, 2013. 28(4).
23. Zhang, Y., et al., Er: YAG laser debonding of porcelain laminate veneers. 2018.
24. Gurney, M.L., et al., Using an Er, Cr: YSGG laser to remove lithium disilicate restorations:
A pilot study. The Journal of prosthetic dentistry, 2016. 115(1): p. 90-94.
25. Morford, C.K., et al., Er: YAG laser debonding of porcelain veneers. Lasers in surgery and
medicine, 2011. 43(10): p. 965-974.
26. Zheng, J., et al., SEM X-ray microanalysis of nanoparticles present in tissue or cultured
cell thin sections, in Characterization of Nanoparticles Intended for Drug Delivery. 2011,
Springer. p. 93-99.
27. Steinhauser, H.C., et al., Micro-shear bond strength and surface micromorphology of a
feldspathic ceramic treated with different cleaning methods after hydrofluoric acid
etching. Journal of Applied Oral Science, 2014. 22(2): p. 85-90.

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