Interpenetrating network ceramic-resin composite dental restorative materials

Nanoindentation creep: The impact of water and artificial saliva storage on milled and 3D-printed resin composites

PURPOSE

This study evaluated the effects of artificial saliva and distilled water on the nanoindentation creep of different 3D-printed and milled CAD-CAM resin composites.

MATERIAL AND METHODS

Disk-shaped specimens were subtractively fabricated from polymer-infiltrated ceramic network (EN) and reinforced resin composite (B) and additively from resin composite (C) and hybrid resin composite (VS) using digital light processing (DLP). Specimens from each material were divided into two groups according to their storage conditions (artificial saliva or distilled water for 3 months). Creep was analyzed by nanoindentation testing. Statistical analysis was done using two-way ANOVA, one-way ANOVA, Bonferroni post hoc tests, and independent t-test (α = 0.05).

RESULTS

The main effects of material and storage conditions, and their interaction were statistically significant on nanoindentation (p < 0.001). Storage condition had the greatest influence (partial eta squared ηP 2 = 0.370), followed by the material (ηP 2 = 0.359), and the interaction (ηP 2 = 0.329). The nanoindentation creep depths after artificial saliva storage ranged from 0.34 to 0.51 µm and from 0.50 to 0.87 µm after distilled water storage. One of the additively manufactured groups had higher nanoindentation creep depths in both storage conditions.

CONCLUSIONS

All specimens showed comparable performance after artificial saliva storage, but increased nanoindentation creep after distilled water storage for 3 months. The subtractive CAD-CAM blocks showed superior dimensional stability in terms of nanoindentation creep depths in both storage conditions. Additively manufactured composite resins had lower dimensional stability than one of the subtractively manufactured composites, which was demonstrated as having higher creep deformation and maximum recovery. However, after artificial saliva storage, one of the additively manufactured resins had dimensional stability similar to that of subtractively manufactured.

The effect of different materials and cavity designs on fracture resistance of ceramic partial coverage

BACKGROUND

Two intra-coronal preparation designs with varying extensions of cuspal coverage can perform differently regarding their fracture resistance against introral forces.

METHODS

Two materials (IPS e-max CAD [EX], VITA ENAMIC [EN]), and two different preparation designs (EX-D1), (EX-D2), (EN-D1), and (EN-D2) were investigated to compare their fracture resistance. A total of 40 (n = 40) caries free human mandibular molars were used. All the prepared samples were scanned using CEREC Omnicam scanner and the preparations were checked by the software for any sharpness and undercuts before restoration designing and fabrication. All restorations were milled using Cerec MCXL 4.4 milling machine. Duo-Link resin cement was used for cementation. After thermocycling and chewing simulation, all samples were loaded in the Universal testing machine in order to evaluate fracture resistance of all samples.

RESULTS

Fracture resistance testing revealed that e-max CAD (2134 N) showed statistically significantly higher mean fracture resistance values than Vita Enamic (1728 N). On the other hand, there was no statistically significant difference between mean fracture resistances between the two tested designs.

CONCLUSIONS

Within the confines of this investigation, it can be said that although preparation design had no appreciable impact on fracture resistance, the CAD/CAM ceramic material utilized did.

CLINICAL SIGNIFICANCE

When restoring compound cavitties indirectly; a conservative defect oriented approach should be used. Glass Ceramic are prefered as restorative material.

Advances in ceramics for tooth repair: From bench to chairside

OBJECTIVES

To give a comprehensive review of advancement in dental ceramics, fabrication methods, and the challenges associated with clinical application.

DATA, SOURCES AND STUDY SELECTION

Researches on chemical composition, biomechanical behaviors, optical properties, bonding strategies and fabrication methods were included. The search of articles was independently conducted by two authors in the PubMed, Scopus, Medline and Web of Science.

CONCLUSIONS

Dental ceramics have shown significant advancements in terms of esthetics and function. However, improving fracture toughness without compromising optical properties remains a challenge. Repairing fractured zirconia or glass-matrix ceramic prostheses with the same material is difficult due to the sintering process. Developing innovative bonding techniques that provide strong and long-lasting bonding strength between ceramics and tooth structures poses a recurring obstacle.

CLINICAL SIGNIFICANCE

Despite the emergence of dental ceramics and fabrication techniques, certain limitations such as susceptibility to brittleness and fracture still exist. Therefore, the current review provided valuable information around the advanced dental ceramics in tooth repair. The laboratory test data and the clinical outcome are also presented in details, aiming to guide clinicians in making informed decisions regarding ceramic restorations.

Microstructural investigation of hybrid CAD/CAM restorative dental materials by micro-CT and SEM

OBJECTIVES

An increasing number of CAD/CAM (computer-aided design/computer-aided manufacturing) hybrid materials have been introduced to the dental market in recent years. In addition, CAD/CAM hybrid materials for additive manufacturing (AM) are becoming more attractive in digital dentistry. Studies on material microstructures using micro-computed tomography (µ-CT) combined with scanning electron microscopy (SEM) have only been available to a limited extent so far.

METHODS

One CAD/CAM three-dimensional- (3D-) printable hybrid material (VarseoSmile Crown plus) and two CAD/CAM millable hybrid materials (Vita Enamic; Voco Grandio), as well as one direct composite material (Ceram.x duo), were included in the present study. Cylindrical samples with a diameter of 2 mm were produced from each material and investigated by means of synchrotron radiation µ-CT at a voxel size of 0.65 µm. Different samples from the same materials, obtained by cutting and polishing, were investigated by SEM.

RESULTS

The 3D-printed hybrid material showed some agglomerations and a more irregular distribution of fillers, as well as a visible layered macrostructure and a few spherical pores due to the printing process. The CAD/CAM millable hybrid materials revealed a more homogenous distribution of ceramic particles. The direct composite material showed multiple air bubbles and microstructural irregularities based on manual processing.

SIGNIFICANCE

The µ-CT and SEM analysis of the materials revealed different microstructures even though they belong to the same class of materials. It could be shown that µ-CT and SEM imaging are valuable tools to understand microstructure and related mechanical properties of materials.

Laser debonding of ultrathin occlusal veneers fabricated from different CAD/CAM ceramic materials

BACKGROUND

Erbium lasers safely offer the possibility of reuse for debonded restorations. Since these lasers have a high affinity for water molecules, they are absorbed by resin cement causing explosive ablation of the cement and thus, the restoration debonds. The efficiency of this process depends on many factors, including the ceramic type, its chemical composition and thickness. Therefore, this study was designed to test the time taken to debond ultrathin occlusal veneers made of three types of milled ceramic materials and evaluate the integrity of these restorations after debonding.

METHODS

Three ceramic types were evaluated in this study: lithium disilicate (IPS Emax CAD), highly condensed lithium disilicate (GC initial®LiSi), and translucent zirconia (Katana zirconia STML). Each group consisted of 8 occlusal veneers of 0.5 mm thickness. The samples were cemented to the occlusal surfaces of the upper molar teeth. An Er; Cr: YSGG laser was applied to the occlusal veneers using the scanning method, and time until debonding was calculated. The debonded samples were then inspected under a stereomicroscope for possible damage. Numerical data are presented as the mean with 95% confidence interval (CI), standard deviation (SD), minimum (min.) and maximum (max.) values. Normality and variance homogeneity assumptions were confirmed using Shapiro-Wilk's and Levene's tests, respectively. Data were normally distributed and were analyzed using one-way ANOVA followed by Tukey's post hoc test. The significance level was set at p < 0.05 for all tests. Statistical analysis was performed with R statistical analysis software version 4.3.2 for Windows (R Core Team (2023). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/).

RESULTS

There was no significant difference in debonding time between the different materials (p = 0.995). The longest debonding time was found for Katana STML (87.52 ± 20.45) (seconds), followed by Emax (86.94 ± 20.63) (seconds), while the lowest value was found for LiSi initial (86.14 ± 25.16) (seconds). In terms of damage to the debonded veneers, The Emax and zirconia samples showed no damage. However, 40% of the LiSi samples fractured during debonding, and 20% exhibited cracks. Only 40% of the LiSi samples were sound after debonding.

CONCLUSION

Er; Cr: YSGG laser can be used efficiently to remove ceramic occlusal veneers. However, its effect on LiSi restorations needs further research.

In-vitro evaluation of wear characteristics, microhardness and color stability of dental restorative CAD/CAM materials

The aim of this study was to demonstrate the vertical and volumetric wear characteristics of CAD/CAM materials. The microhardness and color stability were evaluated. A polymer infiltrated ceramic network CAD/CAM block, resin nanoceramic CAD/CAM blocks, a resin composite, and enamel tissue were investigated. Samples were loaded in a chewing simulator. Other samples were aged and immersed in coffee. Color change was evaluated using the digital image analysis and a spectrophotometer. The data were analyzed using Kolmogorov-Smirnov, Kruskal Wallis, Mann Whitney U, Friedman, Spearman's rho tests (p<0.05). The lowest level of wear was obtained in enamel tissue group 0.20 (Q1:0.14; Q3:0.27μm). Resin composite group 2.48 (Q1:2.12; Q3:2.92) showed lower level of discoloration. No agreement was obtained between the digital image analysis and spectrophotometer data (Spearman's rho -0.314, p=0.014). Similar wear rate to the natural enamel tissue was obtained for Vita Enamic. Digital image analysis was considered a promising technique for monitoring the color change.

Interblock and intrablock homogeneity of CAD-CAM composites mechanical properties

The purpose of this study was to characterize the homogeneity of the mechanical properties of commercial CAD-CAM composites between different blocks of the same material (interblock homogeneity) and within each block between the internal and external parts (intrablock homogeneity). Tetric CAD (TET); Katana Avencia (KAT); Cerasmart 270 (CER); Grandio (GRN) and Vita Enamic (ENA) were tested for flexural strength (σf), flexural modulus (Ef), flexural load energy (Ur) and hardness (HV). Results showed significant differences in interblock homogeneity of σf, Ef and Ur for TET, KAT, CER and ENA. In addition, significant differences in interblock homogeneity of HV for TET, CER and GRN were found. Moreover, significant differences in intrablock homogeneity of σf, Ef and Ur were found for KAT, CER, GRN and ENA, as well as for HV of all the tested materials except CER. Weibull modulus was highest for GRN, followed by ENA, KAT, TET then CER.

Crack Propagation and Fatigue Performance of Partial Posterior Indirect Restorations: An Extended Finite Element Method Study

Dental ceramics are susceptible to slow, progressive crack growth after cyclic loading. The purpose of this study was to investigate the progressive patterns of cracks in two different types of CAD/CAM ceramic materials used with three different partial posterior indirect restoration (PPIR) designs and to determine the materials' failure risk using a fatigue test. Standard initial cracks were formed in Standard Tessellation Language (STL) files prepared for three different PPIRs. The materials chosen were monolithic lithium disilicate (LS) and polymer-infiltrated ceramic networks (PICNs). The extended finite element method (XFEM) was applied, and the fatigue performance was examined by applying a 600 N axial load. The cracks propagated the most in onlay restorations, where the highest displacement was observed. In contrast, the most successful results were observed in overlay restorations. Overlay restorations also showed better fatigue performance. LS materials exhibited more successful results than PICN materials. LS materials, which can be used in PPIRs, yield better results compared to PICN materials. While inlay restorations demonstrated relatively successful results, overlay and onlay restorations can be specified as the most and the least successful PPIR types, respectively.

The effect of in-office bleaching agents on the Vickers hardness and surface topography of polished and unpolished CAD/CAM composite materials

In-office bleaching, using hydrogen peroxide, is effective to remove dental enamel stains. However, bleaching agents can deteriorate surface properties of CAD-CAM materials. This in vitro study aimed to investigate the effect of in-office bleaching agents on Vickers hardness and surface topography of polished and unpolished dental CAD-CAM composite materials (Grandio blocs, Lava Ultimate, BRILLIANT Crios, Cerasmart), and a polymer-infiltrated ceramic network block (Vita Enamic). The specimens were randomly divided into two groups: unpolished or polished. The micro-hardness and surface topography of each group were measured before bleaching, after a 60 min bleaching period, and 24-h and one-month post-bleaching. In-office bleaching significantly influenced the Vickers hardness of both the polished and unpolished CAD/CAM composite blocks, with Vita Enamic exhibiting the least hardness stability among all groups. Furthermore, in-office bleaching significantly influenced the surface roughness of unpolished CAD/CAM composite blocks. There was a significant difference in hardness reduction between the polished and unpolished specimens for most of the investigated materials at different time points. The bleaching did not influence the surface roughness of the investigated polished group, except for Vita Enamic and Lava Ultimate. However, it did influence the surface roughness of the investigated materials in the unpolished group.

Influence of different surface treatment on bonding of metal and ceramic Orthodontic Brackets to CAD-CAM all ceramic materials

BACKGROUND

Developing efficient bonding techniques for orthodontic brackets and all-ceramic materials continues to pose a clinical difficulty. This study aimed to evaluate the shear bond strengths (SBS) of metal and ceramic brackets to various all-ceramic CAD-CAM materials, such as lithium disilicate CAD (LDS-CAD), polymer-infiltrated ceramic (PIC), zirconia-reinforced lithium silicate glass ceramic (ZLS), and 5YTZP zirconia after different surface treatments and thermal cycling.

MATERIALS AND METHODS

The samples were divided into two groups to be bonded with ceramic and metal lower incisor brackets. Each group was subdivided into a control group devoid of any surface treatment, 10% HF acid (HFA) etching, ceramic etch & prime (MEP), Al2O3 air abrasion, and medium grit diamond bur roughening. After surface treatment, brackets were bonded with composite resin cement, thermal cycled, and tested for shear bond strength. The failed surfaces were evaluated with a digital microscope to analyse the type of failure. The data were statistically analysed using a one-way ANOVA and Tukey HSD tests at p < 0.05.

RESULTS

The highest mean bond strengths were found with HFA etching in LDS-CAD (13.17 ± 0.26 MPa) and ZLS (12.85 0.52 MPa). Diamond bur recorded the lowest mean bond strength roughening across all the ceramic groups. There were significant differences in mean shear bond values per surface treatment (p < 0.001) and ceramic materials.

CONCLUSION

Among the surface treatment protocols evaluated, HFA etching and MEP surface treatment resulted in enhanced bond strength of both ceramic and metal brackets to CAD-CAM all ceramic materials.

Bonding Characteristics of Silane Coupling Agent and MMA-Containing Primer to Various Composite CAD/CAM Blocks

This study evaluated the bonding characteristics of a silane coupling agent (SCA) and a methyl methacrylate (MMA)-containing primer (MCP) for 11 types of commercial composite blocks (CBs) for sandblasted and non-sandblasted surfaces. The shear bond strength (SBS) was measured according to ISO 29022: Notched-edge shear bond strength test. The SBS results demonstrated statistically significant differences between the CBs under all identical conditions. For the non-sandblasted groups, the SBSs of MCP-treated specimens were significantly higher than those of SCA-treated specimens for all but two CBs. Comparing the two treatments in sandblasted groups, the SBS was significantly higher for seven out of 11 MCP-treated RCB specimens, in contrast with three cases for the SCA-treated group. Two-way ANOVA for SBS showed the interaction effect between sandblasting and primer type for specific CBs, indicating that the sandblasting treatment improved SBS more effectively for SCA-treated specimens. Moreover, the effect of the SCA treatment was more material-dependent compared to that of the MCP treatment, which did not achieve a strong bond in all CBs but proved more effective than the SCA treatment, especially for non-sandblasted surfaces.

The effect of water storage on nanoindentation creep of various CAD-CAM composite blocks

BACKGROUND

To study the effect of water storage (3 months) on the creep deformation of various CAD-CAM composite structures at the nanoscale and compare it to that at the macroscale.

METHODS

Seven CAD-CAM blocks were investigated: five resin-composite blocks (RCB), one polymer-infiltrated ceramic network (PICN) block, and one ceramic-filled polyetheretherketone (PEEK) block. Specimens of each material (n = 6) were separated into two groups (n = 3) according to their storage conditions (24 h dry storage at 23˚C and 3 months storage in 37˚C distilled water). Nano-indentation creep measurements were undertaken (creep depth measured in µm) using a nanoindenter (Nanovea) equipped with Berkovich three-sided pyramidal diamond tip. The machine was set for the chosen parameters: a load of 20 gf, a pause of 20 s, and the material type. Thirty indentations on 3 samples were made for each material for each test. Data were analysed using two-way ANOVA followed by one-way ANOVA and Bonferroni post hoc tests and independent t-test (< 0.05) for comparisons between the materials.

RESULTS

The nanoindentation creep depth after 24 h storage ranged from 0.09 to 0.33 μm and increased after 3 months storage in distilled water to between 0.28 and 3.46 μm. There was a statistically significant difference in nanoindentation creep behaviour between the two storage conditions for each investigated material (independent t-test) and between all materials (Bonferroni post hoc). There was a non-significant negative correlation between nanoindentation creep (µm) and filler weight% at 24 h dry storage but a significant correlation at 3 months of water storage. A further non-significant positive correlation between nanoindentation creep (µm) and bulk compressive creep (%) was found.

CONCLUSION

The PICN material showed superior dimensional stability in terms of nanoindentation creep depth in both storage conditions. Other composite blocks showed comparable performance at 24 h dry condition, but an increased nanoindentation creep upon water storage.

Effectiveness of Porcelain Polishing Methods on the Roughness and Color Stability of CAD-CAM Ceramics after Orthodontic Bracket Debonding

Increased utilization of all ceramic restorations for aesthetic consideration in combination with routine adult orthodontic practice has led to numerous clinical challenges. Obtaining adequate bond strength between the orthodontic bracket and all-ceramic restoration and damage to the ceramic surface during the bracket debonding procedure needs to be better understood. This study analyzed the surface texture and color change of glazed and bracket-debonded ceramic CAD-CAM materials and the efficiency of porcelain polishing systems in restoring surface morphology and color. A total of 30 rectangular test specimens from each lithium disilicate CAD (LD-CAD), polymer-infiltrated ceramic (PICN), zirconia-reinforced lithium silicate glass ceramic (ZLS), and 5YTZP zirconia (5YZP) were prepared. The ceramic samples were embedded within acrylic resin, and baseline surface roughness and color were recorded using an optical profilometer and a reflected color spectrophotometer. The porcelain samples were bonded with lower incisor ceramic brackets. The samples were thermocycled 2000 times between 5 and 55 °C. Afterward, the brackets were peeled with bracket-removing pliers. The resin adhesive from the debonded surface was eliminated with tungsten carbide bur, and samples were randomly divided into three subgroups of (n = 10) to be polished with Diapol-twist (DT), a Keramik-Politur 4313B Komet polishing kit (KK), and a Horico diamond polisher (HDP). The polished surface roughness and color were recorded. The data were statistically analyzed using a two-way analysis of variance at p < 0.05. The debonded porcelain surfaces across the groups displayed significantly higher mean surface roughness (Ra) compared to glazed surfaces. The debonded 5YZP showed the least Ra at 0.661 (0.09), while the highest Ra was recorded by PICN at 4.057 (0.82). All of the polishing systems evaluated in the study significantly reduced the surface roughness. However, they were unsuccessful in regaining the surface topography of the glazed surface. The flexible discs (DT) produced the smoothest surface, followed by the diamond-impregnated rubber points (KK). Unpolished porcelain surfaces had a discernable mean color difference from glazed surfaces. Polished surfaces from the different polishing systems among the all-ceramic groups achieved a clinically acceptable mean color difference. Polishing debonded rough porcelain surfaces is imperative, and flexible discs performed better in all of the tested CAD-CAM ceramic materials.

Evaluation of a biobased polycarbonate interpenetrated network in a dental resin composite

Silanization of filler particles in a dental resin composite is achieved by the formation of Si-O-Si bonds, however, these bonds are especially vulnerable to hydrolysis because this covalent bond has a significant ionic character due to the electronegativity differences between the atoms. The objective of this study was to evaluate the use of an interpenetrated network (IPN) as alternative of silanization reaction and to assess its effect in selected properties of experimental photopolymerizable resin composites. The interpenetrate network was obtained during the photopolymerization reaction of organic matrix (BisGMA/TEGDMA) with a biobased polycarbonate. Its characterization was performed via FTIR, flexural strength, flexural modulus, depth of cure, sorption water and solubility. A resin composite formulated with non-silanized filler particles was used as control. The IPN with a biobased polycarbonate was successfully synthesized. The results showed that the IPN based resin composite had higher values of flexural strength, flexural modulus, and degree of double bond conversion than the control (p < 0.05). Polymerization shrinkage, water sorption and solubility were statistically significantly lower than the control resin (p < 0.05). Finally, this study shows there were no statistically significant differences for the biocompatibility outcomes (p > 0.05). The biobased IPN replaces the silanization reaction in resin composites, improving physical and chemical properties. Therefore, IPN with a biobased polycarbonate could be potentially useful in the formulation of dental resin composites.

Micromechanical interlocking structure at the filler/resin interface for dental composites: a review

Dental resin composites (DRCs) are popular materials for repairing caries or dental defect, requiring excellent properties to cope with the complex oral environment. Filler/resin interface interaction has a significant impact on the physicochemical/biological properties and service life of DRCs. Various chemical and physical modification methods on filler/resin interface have been introduced and studied, and the physical micromechanical interlocking caused by the modification of fillers morphology and structure is a promising method. This paper firstly introduces the composition and development of DRCs, then reviews the chemical and physical modification methods of the filler/resin interface, mainly discusses the interface micromechanical interlocking structures and their enhancement mechanism for DRCs, finally give a summary on the existing problems and development potential.

Failure Load and Fatigue Behavior of Monolithic and Bi-Layer Zirconia Fixed Dental Prostheses Bonded to One-Piece Zirconia Implants

No evidence-based prosthetic treatment concept for 3-unit fixed-dental-prostheses (FDPs) on ceramic implants is currently available. Therefore, the aim of this in vitro study was to investigate the failure load and fatigue behavior of monolithic and bi-layer zirconia FDPs supported by one-piece ceramic implants. Eighty 3-unit FDPs supported by 160 zirconia-implants (ceramic.implant; vitaclinical) were divided into 4 groups (n = 20 each): Group Z-HT: 3Y-TZP monolithic-zirconia (Vita-YZ-HT); Group Z-ST: 4Y-TZP monolithic-zirconia (Vita-YZ-ST); Group FL: 3Y-TZP zirconia (Vita-YZ-HT) with facial-veneer (Vita-VM9); Group RL (Rapid-layer): PICN “table-top” (Vita-Enamic), 3Y-TZP-framework (Vita-YZ-HT). Half of the test samples (n = 10/group) were fatigued in a mouth-motion chewing-simulator (F = 98 N, 1.2 million-cycles) with simultaneous thermocycling (5−55 °C). All specimens (fatigued and non-fatigued) were afterwards exposed to single-load-to-failure-testing (Z010, Zwick). Statistical analysis was performed using ANOVA, Tukey’s post-hoc tests and two-sample t-tests (p < 0.05, Bonferroni-corrected where appropriate). All specimens withstood fatigue application. While the effect of fatigue was not significant in any group (p = 0.714), the choice of material had a significant effect (p < 0.001). Material FL recorded the highest failure loads, followed by Z-ST, Z-HT and RL, both with and without fatigue application. Taken together, all tested FDP material combinations survived chewing forces that exceeded physiological levels. Bi-Layer FL and monolithic Z-ST showed the highest resilience and might serve as reliable prosthetic reconstruction concepts for 3-unit FDPs on ceramic implants.

Post-Fatigue Fracture Resistance of Lithium Disilicate and Polymer-Infiltrated Ceramic Network Indirect Restorations over Endodontically-Treated Molars with Different Preparation Designs: An In-Vitro Study

The aim of the present study was to evaluate the fatigue to cyclic and static resistance of indirect restorations with different preparation designs made either of lithium disilicate (LS) or polymer-infiltrated ceramic network (PICN). Eighty-four (n = 84) molars were chosen, endodontically treated, and prepared with standardized MOD cavities. The molars were randomly divided into 6 study groups (n = 14) taking into account the "preparation design'' (occlusal veneer with 1.2 mm occlusal thickness; overlay with 1.6 mm occlusal thickness; adhesive crown with 2 mm occlusal thickness) and the "CAD/CAM material'' (E-max CAD, Ivoclar vivadent; Vita Enamic, Vita). A fatigue test was conducted with a chewing simulator set at 50 N for 1,500,000 cycles. Fracture resistance was assessed using a universal testing machine with a 6 mm diameter steel sphere applied to the specimens at a constant speed of 1 mm/min. A SEM analysis before the fracture test was performed to visually analyze the tooth-restoration margins. A statistical analysis was performed with a two-way ANOVA and a post-hoc pairwise comparison was performed using the Tukey test. The two-way ANOVA test showed that both the preparation design factor (p = 0.0429) and the CAD/CAM material factor (p = 0.0002) had a significant influence on the fracture resistance of the adhesive indirect restorations. The interaction between the two variables did not show any significance (p = 0.8218). The occlusal veneer had a lower fracture resistance than the adhesive crown (p = 0.042) but not lower than the overlay preparation (p = 0.095). LS was more resistant than PICN (p = 0.002). In conclusion, in the case of endodontically treated teeth, overlay preparation seems to be a valid alternative to the traditional full crown preparation, while occlusal veneers should be avoided in restoring non-vital molars with a high loss of residual tooth structure. LS material is more resistant compared to PICN.

Current Protocols for Resin-Bonded Dental Ceramics

Resin-bonded ceramic restorations are common treatment options. Clinical longevity of resin-bonded ceramic restorations depends on the quality and durability of the resin-ceramic bond. The type and composition of the specific ceramic determines the selection of the most effective bonding protocol. Such protocol typically includes a surface pretreatment step followed by application of a priming agent. Understanding of fundamental ceramic properties and chemical compositions enables the clinician to make proper material selection decisions for clinically successful and long-lasting restorations. Based on research accrued over the past decades, this article reviews and discusses current resin-bonding protocols to most commonly used dental ceramics.

3D-Printed Polymer-Infiltrated Ceramic Network with Antibacterial Biobased Silver Nanoparticles

This work aimed at the antimicrobial functionalization of 3D-printed polymer-infiltrated biomimetic ceramic networks (PICN). The antimicrobial properties of the polymer-ceramic composites were achieved by coating them with human- and environmentally safe silver nanoparticles trapped in a phenolated lignin matrix (Ag@PL NPs). Lignin was enzymatically phenolated and used as a biobased reducing agent to obtain stable Ag@PL NPs, which were then formulated in a silane (γ-MPS) solution and deposited to the PICN surface. The presence of the NPs and their proper attachment to the surface were analyzed with spectroscopic methods (FTIR and Raman) and X-ray photoelectron spectroscopy (XPS). Homogeneous distribution of 13.4 ± 3.2 nm NPs was observed in the transmission electron microscopy (TEM) images. The functionalized samples were tested against Gram-positive (Staphylococcus aureus) and Gram-negative (Pseudomonas aeruginosa) bacteria, validating their antimicrobial efficiency in 24 h. The bacterial reduction of S. aureus was 90% in comparison with the pristine surface of PICN. To confirm that the Ag-functionalized PICN scaffold is a safe material to be used in the biomedical field, its biocompatibility was demonstrated with human fibroblast (BJ-5ta) and keratinocyte (HaCaT) cells, which was higher than 80% in both cell lines.

Effect of Sintering and Infiltration Conditions on Nanoscale Dual Network SiO2/Polymethyl Metacrylate Composites Mimicking Human Enamel

OBJECTIVE

The aim of this study was to achieve facile sintering conditions and rapid penetration of organic substances into the structure of sintered silica network on the nano-scale in order to prepare polymer infiltrated ceramic network mimicking human enamel.

METHODS

Stepwise temperature programming (stepwise isothermal firing) was used to create a cohesive ceramic network containing interconnected pores, which is essential to provide polymer/ceramic dual networks. Liquid phase self-penetration, ultrasonic irradiation assisted liquid phase penetration and vapor phase penetration routes were used to infiltrate methyl methacrylate monomers and benzoyl peroxide reagent into the porous silica blocks.

RESULTS

The use of stepwise isothermal firing route, in comparison with high temperature sintering methods, significantly reduces the time and temperature required for the preliminary preparation of the SiO₂ samples and reaching the appropriate interconnected porous structure. The most appropriate method for monomer and oxidant reagents infiltration is to use liquid phase infiltration assisted by ultrasound irradiation of pre-sintered nano-silica blocks. It was found that the amount of infiltrated monomer and oxidizing agent, degree of conversion of the monomer to the polymer and surface hardness of the samples strongly depend on the infiltration route.

CLINICAL SIGNIFICANCE

The use of inexpensive silica nanoparticles and low temperature sintering and the use of ultrasound waves to quickly and effectively penetrate methyl methacrylate monomers and increase the polymerization efficiency lead to the preparation of composites with a transparent appearance and mechanical properties similar to human tooth enamel.

Effects of Streptococcus mutans and their metabolites on the wear behavior of dental restorative materials

The wear behavior of dental restorative materials is highly related to the biolubricating medium in the oral environment. Bacteria, along with their metabolic products, are essential substances in the oral cavity and have not been studied as a potential factor affecting lubrication performance during mastication. In this study, the effects of the Streptococcus mutans bacterial cells and their metabolites were investigated on the wear behavior of resin composites, polymer-infiltrated ceramic networks and zirconium-lithium silicate glass-ceramics. A reciprocating friction test and quantitative analysis of the wear morphology were utilized to determine the coefficient of friction (COF) and wear resistance of the test materials. The results showed that the bacterial metabolite medium significantly reduces the COF and wear rate of the three restorative materials and provide better protection against superficial abrasion. When tested under lactic acid medium, a key acid production in bacterial metabolites, similar wear reduction results were observed in the three materials, which confirmed that lactic acid should be accountable for the excellent lubricating property of bacterial metabolites. Furthermore, the resin composite with lower wettability exhibited a more significant wear reduction than the other two materials when lubricating with a bacterial metabolite medium. These findings provide novel insights into the biological basis of lubrication mechanisms in the oral cavity under high-loading and low-velocity conditions.

Ceramic Toughening Strategies for Biomedical Applications

Aiming at shortage of metal materials, ceramic is increasingly applied in biomedicine due to its high strength, pleasing esthetics and good biocompatibility, especially for dental restorations and implants, artificial joints, as well as synthetic bone substitutes. However, the inherent brittleness of ceramic could lead to serious complications, such as fracture and disfunction of biomedical devices, which impede their clinical applications. Herein, several toughening strategies have been summarized in this review, including reinforcing phase addition, surface modification, and manufacturing processes improvement. Doping metal and/or non-metal reinforcing fillers modifies toughness of bulk ceramic, while surface modifications, mainly coating, chemical and thermal methods, regulate toughness on the surface layer. During fabrication, optimization should be practiced in powder preparation, green forming and densification processes. Various toughening strategies utilize mechanisms involving fine-grained, stress-induced phase transformation, and microcrack toughening, as well as crack deflection, bifurcation, bridging and pull-out. This review hopes to shed light on systematic combination of different toughening strategies and mechanisms to drive progress in biomedical devices.

3D-Printed Strong Dental Crown with Multi-Scale Ordered Architecture, High-Precision, and Bioactivity

Mimicking the multi-scale highly ordered hydroxyapatite (HAp) nanocrystal structure of the natural tooth enamel remains a great challenge. Herein, a bottom-up step-by-step strategy is developed using extrusion-based 3D printing technology to achieve a high-precision dental crown with multi-scale highly ordered HAp structure. In this study, hybrid resin-based composites (RBCs) with "supergravity +" HAp nanorods can be printed smoothly via direct ink writing (DIW) 3D printing, induced by shear force through a custom-built nozzle with a gradually shrinking channel. The theoretical simulation results of finite element method are consistent with the experimental results. The HAp nanorods are first highly oriented along a programmable printing direction in a single printed fiber, then arranged in a layer by adjusting the printing path, and finally 3D printed into a highly ordered and complex crown structure. The printed samples with criss-crossed layers by interrupting crack propagation exhibit a flexural strength of 134.1 ± 3.9 MPa and a compressive strength of 361.6 ± 8.9 MPa, which are superior to the corresponding values of traditional molding counterparts. The HAp-monodispersed RBCs are successfully used to print strong and bioactive dental crowns with a printing accuracy of 95%. This new approach can help provide customized components for the clinical restoration of teeth.

Contact fracture test of monolithic hybrid ceramics on different substrates for bruxism

OBJECTIVES

To determine the minimum thickness required for a monolithic hybrid ceramic crown on different substrates (soft vs stiff) used in posterior dentition for bruxism.

METHODS

80 polymer-infiltrated ceramic networks Vita Enamic (PICN VE) disc specimens with four different occlusal thicknesses (0.8, 1.2, 1.6 and 2.0 mm), were produced using a computer-aided design/manufacturing system, and cemented on a stiff (zirconia) or soft (polyamide) substrate of 4-mm thickness. The ten specimens, in soft or stiff groups, were subjected to compressive loading by a MTS machine until fracture or maximum load (4500 N) was reached. The unbroken specimens were examined using optical coherence tomography. Eight axisymmetric finite element models and eight 3D models comprising the four different occlusal thicknesses and two substrates under different vertical loads and sliding movements were constructed. The maximum principal stress was selected to evaluate the stress distribution in this study.

RESULTS

The fracture resistance of the specimens was significantly different between the two substrates (P < 0.001). Fracture resistance was positively associated with specimen thickness (r = 0.597 and 0.896 for the soft and stiff substrate respectively). Specimens on the soft substrate had lower fracture loads, whilst cone cracks were observed in unbroken samples on different soft/stiff substrate prior to final fracture. The finite element analysis confirmed that samples on the stiff substrate had lower maximum principal stress values than those on the soft substrate. For the maximum principal stress not to exceed the flexural strength of PICN VE, a stiff substrate and minimum thickness of 2.0 mm are required for the prostheses.

SIGNIFICANCE

A minimum 2.0 mm thick, stiff substrate was needed for bruxism as shown by the effect of high/large chewing force on the posterior dentition of monolithic PICN VE crowns.

Functional or Nonfunctional Cusps Preservation for Molars Restored with Indirect Composite or Glass-Ceramic Onlays: 3D FEA Study

Evidence regarding the effect of the onlay preparation design for different CAD/CAM restorative materials considering the preservation of cusps is lacking. Molars were 3D-modeled in four preparation designs for onlay restoration: traditional design with functional cusp coverage (TFC), non-retentive design with functional cusp coverage (NFC), traditional design with non-functional cusp coverage (TNFC) and non-retentive design with non-functional cusp coverage (NNFC). The restorations were simulated with two CAD/CAM restorative materials: LD—lithium disilicate (IPS e.max CAD) and RC—resin composite (GrandioBloc). A 100 N axial load was applied to the occlusal surface, simulating the centric contact point. Von Mises (VM) and maximum principal (Pmax) stress were evaluated for restorations, cement layer and dental substrate. The non-retentive preparation design reduced the stress concentration in the tooth structure in comparison to the conventional retentive design. For LD onlays, the stress distribution on the restoration intaglio surface showed that the preparation design, as well as the prepared cusp, influenced the stress magnitude. The non-retentive preparation design provided better load distribution in both restorative materials and more advantageous for molar structure. The resin composite restoration on thenon-functional cusp is recommended when the functional cusp is preserved in order to associate conservative dentistry and low-stress magnitude.

Clinical outcomes of all-ceramic single crowns and fixed dental prostheses supported by ceramic implants: A systematic review and meta-analyses

Objective

To analyze the clinical outcomes of all‐ceramic single crowns (SCs) and fixed dental prostheses (FDPs) supported by ceramic implants.

Materials and Methods

Based on a focused question and customized PICO framework, electronic (Medline/EMBASE/Cochrane) and manual searches for studies reporting the clinical outcomes of all‐ceramic SCs and FDPs supported by ceramic implants ≥12 months were performed. The primary outcomes were reconstruction survival and the chipping proportion. The secondary outcomes were implant survival, technical complications, and patient‐related outcome measurements. Meta‐analyses were performed after 1, 2, and 5 years using random‐effect meta‐analyses.

Results

Eight of the 1,403 initially screened titles and 55 full texts were included. Five reported on monolithic lithium disilicate (LS2) SCs, one on veneered zirconia SCs, and two on veneered zirconia SCs and FDPs, which reported all on cement‐retained reconstructions (mean observation: 12.0–61.0 months). Meta‐analyses estimated a 5‐year survival rate of 94% (95% confidence interval [CI]: 82%–100%) for overall implant survival. Reconstruction survival proportions after 5 years were: monolithic LS2, 100% (95%CI: 95%–100%); veneered zirconia SCs, 89% (95%CI: 62%–100%); and veneered zirconia FDPs 94% (95%CI: 81%–100%). The chipping proportion after 5 years was: monolithic LS2, 2% (95%CI: 0%–11%); veneered zirconia SCs, 38% (95%CI: 24%–54%); and veneered zirconia FDPs, 57% (95%CI: 38%–76%). Further outcomes were summarized descriptively.

Conclusions

Due to the limited data available, only tendencies could be identified. All‐ceramic reconstructions supported by ceramic implants demonstrated promising survival rates after mid‐term observation. However, high chipping proportions of veneered zirconia SCs and, particularly, FDPs diminished the overall outcome. Monolithic LS2 demonstrated fewer clinical complications. Monolithic reconstructions could be a valid treatment option for ceramic implants.

Endocrowns Clinical Performance and Patient Satisfaction: A Randomized Clinical Trial of Three Monolithic Ceramic Restorations

PURPOSE

The purpose of this randomized, double-blind, clinical trial was to assess the survival of endocrowns made from three different monolithic ceramic materials, and to evaluate patient satisfaction.

MATERIALS AND METHODS

Fifty-three patients (sixty root canal treated molar teeth) were enrolled. Teeth were prepared to a flat butt-joint margin and randomly divided between three material groups: lithium disilicate-reinforced glass-ceramic, monolithic zirconia and polymer infiltrated hybrid ceramic. Predefined cementation protocols were used. Clinical assessment using modified United States Public Health Service (USPHS) criteria was carried out after two years by two independent clinicians blinded to the material used. Radiographic examination was conducted to check for the presence of caries, excess cement, and periapical infection. Statistical analysis was performed using the Kruskal Wallis and Wilcoxon signed-rank tests as well as the Kaplan-Meier survival estimate.

RESULTS

Forty-eight patients were available for assessment after 2 years (recall rate 90.6%). The overall Kaplan-Meier survival estimate among all groups was 90.9% with no statistically significant difference between the groups (p = 0.17). Three zirconia endocrowns debonded after 9, 10 and 13 months (82.4% survival rate), while 2 hybrid ceramic endocrowns chipped/fractured (89.5% survival rate). Lithium disilicate endocrowns had a 100% survival rate. The Kruskal Wallis test revealed no statistically significant difference between the groups in the USPHS criteria ratings and the radiographic assessment (P>0.05). Patient satisfaction ranged from 82.3% in the zirconia group to 100% in both the lithium disilicate and hybrid ceramic groups.

CONCLUSIONS

Endocrowns provide a predictable option for the restoration of endodontically treated molar teeth in the short term. Lithium disilicate-reinforced ceramic had fewer complications and required less intervention compared with zirconia and hybrid ceramics. Long-term follow-up is required to substantiate these study results.

Evaluation of Polishing Systems for CAD/CAM Polymer-Infiltrated Ceramic-Network Restorations

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of five different polishing systems on a computer-aided design and computer-aided manufacturing (CAD/CAM) polymer-infiltrated ceramic-network restoration with nanoscale assessment using atomic force microscopy (AFM) and visual assessment performed by dental school senior students and faculty members.

METHOD

Forty-eight full coverage crowns were milled out of polymer-infiltrated ceramic-network CAD/CAM blocks (Vita Enamic) for polishing with one company proprietary, two ceramic and two composite polishing systems. The prepared crowns were divided into six groups: (1) no polishing (control); (2) polishing with Vita Enamic Polishing Kit (VEna); (3) polishing with Shofu Porcelain Laminate Polishing Kit (SCer); (4) polishing with Brasseler Dialite Feather lite All- Ceramic Adjusting & Polishing System (BCer); (5) polishing with Shofu Composite Polishing Kit (SCom); and (6) polishing with Brasseler Composite Polishing Kit (BCom). The polished crown surface topography was observed, and surface roughness and area were measured with AFM. In addition, polished crowns were visually assessed by 15 senior dental students and 15 dental school faculty members.

RESULTS

All polishing treatments significantly reduced the surface roughness and area of the crown compared with the control. SCom and BCom showed significantly higher surface area than VEna, and the SCer and BCer groups were intermediate, showing no significant difference from either VEna or SCom and BCom. There were no significant differences in surface roughness between any of the systems. Dental students and faculty members classified the groups polished with VEna, SCer, and BCer groups as clinically acceptable, and they selected BCer group as the best polished restorations and the control group as the least polished restorations.

CONCLUSIONS

Ceramic and composite polishing systems produced similar polishing results as that observed using a company proprietary polishing system. However, effectiveness for polishing using a company proprietary and ceramic polishing system tends to be higher than composite polishing systems.

The effect of different storage media on the monomer elution and hardness of CAD/CAM composite blocks

OBJECTIVE

This study aimed to assess the effect of different storage media on the hardness and monomer elution of CAD/CAM composite blocks.

METHODS

Five resin-composite blocks (RCB), one polymer-infiltrated ceramic network (PICN) block (Enamic (EN)), one ceramic-filled poly ether ether ketone (PEEK) block (Dentokeep (DK)), and one feldspathic ceramic block. Microhardness was measured using a Vickers indenter tester (FM-700, Future Tech Corp., Japan). In addition 4 conventional resin-composites were investigated for monomer elution using high performance liquid chromatography (HPLC) after storage in different media for 3 months. The data were analysed by three-way ANOVA, two-way ANOVA, one-way ANOVA, Tukey's post hoc test and the independent t-test (α=0.05 for all tests).

RESULTS

The specimens stored in the water had a hardness reduction ranging from 0.9% to 24.4%. In artificial saliva, the specimens had a hardness reduction ranging from 2.8% to 23.2%. The hardness reduction percentage in 75% Ethanol/Water (E/W) ranged between 3.8% and 35.3%. All materials, except GR (resin-composite block) and DK (Polyetheretherketone (PEEK)), showed a variable extent of monomer elution into 75% E/W with significantly higher amounts eluted from conventional composites. GRA and GND (conventional resin-composites) eluted TEGDMA in artificial saliva and GRA eluted TEGDMA in water.

SIGNIFICANCE

The hardness of CAD/CAM composite blocks was affected by different storage media, and they were not as stable as ceramic, with PICN exhibited superior hardness stability to all of the resin-composite blocks in all the storage media and was comparable to ceramic block. The hardness reduction percentage of the CAD/CAM composite blocks was influenced by the filler loading and resin-matrix composition.Minimal or no monomer elution from CAD/CAM blocks was detected.

Failure Load and Fatigue Behavior of Monolithic Translucent Zirconia, PICN and Rapid-Layer Posterior Single Crowns on Zirconia Implants

This laboratory study aimed to evaluate the thermo-mechanical fatigue behavior and failure modes of monolithic and rapid-layer posterior single-crowns (SCs) supported by zirconia implants. Methods: 120 all-ceramic crowns supported by one-piece zirconia implants (ceramic.implant; vitaclinical) were divided into five groups (n = 24 each): Group Z-HT: 3Y-TZP monolithic-zirconia (Vita-YZ-HT); Group Z-ST: 4Y-TZP monolithic-zirconia (Vita-YZ-ST); Z-XT: 5Y-TZP monolithic-zirconia (Vita-YZ-XT); Group E: monolithic-polymer-infiltrated ceramic network (PICN,Vita-Enamic); Group RL (rapid layer): PICN-“table-top” (Vita-Enamic), 3Y-TZP-framework (Vita-YZ-HT). Half of the specimens of each group (n = 12) were exposed to fatigue with cyclic mechanical loading (F = 198N, 1.2-million cycles) and simultaneous thermocycling (5–55 °C). Single-load-to-failure testing (Z010, Zwick) was performed for all specimens without/with fatigue application. Data analysis was performed using ANOVA, Tukey’s post-hoc test, two-sample t-test and Bonferroni correction (p < 0.05). Results: All specimens survived fatigue exposure. Significant differences in failure loads were detected among groups (p ≤ 0.004). Materials Z-HT and Z-ST showed the highest failure loads followed by Z-XT, RL and E. The influence of fatigue was only significant for material RL. Conclusions: All types of tested materials exceeded clinically acceptable failure load values higher than 900N and can be recommended for clinical use. Z-HT and Z-ST appear to be highly reliable towards fatigue. Rapid-layer design of PICN and YZ-HT might be an interesting treatment concept for posterior implant SCs.

Survival of implant-supported resin-matrix ceramic crowns: In silico and fatigue analyses

OBJECTIVE

To evaluate the fatigue survival, failure mode, and maximum principal stress (MP Stress) and strain (MP Strain) of resin-matrix ceramic systems used for implant-supported crowns.

METHODS

Identical molar crowns were milled using four resin-matrix ceramics (n = 21/material): (i) Shofu Hard, (ii) Cerasmart (iii) Enamic, and (iv) Shofu HC. Crowns were cemented on the abutments, and the assembly underwent step-stress accelerated-life testing. Use level probability Weibull curves at 300 N were plotted and the reliability at 300, 500 and 800 N was calculated for a mission of 50,000 cycles. Fractographic analysis was performed using stereomicroscope and scanning electron microscope. MP Stress and MP Strain were determined by finite element analysis.

RESULTS

While fatigue dictated failures for Cerasmart (β > 1), material strength controlled Shofu Hard, Enamic, and Shofu HC failures (β < 1). Shofu HC presented lower reliability at 300 N (79%) and 500 N (59%) than other systems (>90%), statistically different at 500 N. Enamic (57%) exhibited a significant reduction in the probability of survival at 800 N, significantly lower than Shofu Hard and Cerasmart; however, higher than Shofu HC (12%). Shofu Hard and Cerasmart (>93%) demonstrated no significant difference for any calculated mission (300-800 N). Failure mode predominantly involved resin-matrix ceramic fracture originated from occlusal cracks, corroborating with the MP Stress and Strain location, propagating through the proximal and cervical margins.

SIGNIFICANCE

All resin-matrix ceramics crowns demonstrated high probability of survival in a physiological molar load, whereas Shofu Hard and Cerasmart outperformed Enamic and Shofu HC at higher loads. Material fracture comprised the main failure mode.

Load capacity of occlusal veneers of different restorative CAD/CAM materials under lateral static loading

OBJECTIVE

The aim of this in vitro study was to analyze the failure of occlusal veneers made of three different restorative CAD/CAM materials under lateral static loading.

MATERIALS AND METHODS

Sixty standardized semi-anatomical occlusal veneers were fabricated on natural lower molars from three different CAD/CAM materials: hybrid ceramic (Vita Enamic), lithium disilicate (IPS e. max CAD) and translucent zirconia (Bruxzir). The specimens were mechanically loaded by a custom-made device attached to a universal testing machine (MTS 858 Mini Bionix II, MN, USA). Static lateral loading was applied on the buccal cusp of the occlusal veneer until failure. Failure loads were recorded, and the types of failure noted for each group. 3D finite element (FE) models simulating the actual test set-up were further employed to evaluate the stresses within the tooth-restoration complex to help interpret the experimental results.

RESULTS

Occlusal veneers made from zirconia recorded a significantly higher mean failure load (843.1 ± 141.5 N) than specimens of the other two materials (p < 0.05). There was no statistically significant difference between the lithium disilicate (493.21 ± 102.24 N) and the hybrid ceramic (499.6 ± 123.1 N) groups (p = 0.863). 74% of the hybrid ceramic and 84% of the lithium disilicate specimens showed veneer fracture, whereas 78% of the zirconia veneers showed debonding. Comparison of the FE-predicted stresses with the different failure strengths corroborated with the experimental results.

CONCLUSION

Lateral loading caused failure of occlusal veneers at loads significantly lower than those reported for axial loading. Among the materials tested, zirconia veneers showed the highest resistance to failure, with the main failure mode being debonding under lateral loading. The other two material groups failed mainly by veneer fracture at lower loads.

HIGHLIGHTS

- A novel device was used for testing occlusal veneers under lateral static loading. - 3D-FE analysis explained and corroborated the experimental results. - The relationship between vertical and horizontal forces acting on teeth has been described. - The study highlights the harm of excursive contacts on ceramic restorations.

Influence of polymerization pressure and post-cure treatment on conversion degree and viscoelastic properties of polymer infiltrated ceramic network

This study aimed at determining an optimum polymerization pressure for Polymer Infiltrated Ceramic Network (PICN) blocks by characterizing the conversion degree (DC) and the viscoelastic properties of experimental PICN blocks polymerized at 90 °C under various high pressures followed or not by post-cure treatment (PC). Near infrared analysis and dynamic mechanical analysis were used to characterize DC and viscoelastic properties of sixteen PICN: one control (thermo-cured) and fifteen experimental groups (one thermo-cured followed by PC and fourteen high pressure polymerized PICN, in the range of 50-350 MPa without and with PC). Conversion degree of high pressure polymerized PICN blocks without post curing displays an optimum between 100 and 150 MPa resulting in an improved E' and T_g. Post curing induces a higher DC with a controversial effect on thermomechanical properties. The results suggested that 100-150 MPa without PC is an optimum polymerization parameter, resulting in PICN blocks with significantly better DC, T_g, E'.

Mechanical stability and technical outcomes of monolithic CAD/CAM fabricated abutment-crowns supported by titanium bases: An in vitro study

OBJECTIVES

To evaluate mechanical stability (survival and complication rates) and bending moments of different all-ceramic monolithic restorations bonded to titanium bases (hybrid abutment-crowns) or to customized titanium abutments compared to porcelain-fused-to-metal crowns (PFM) after thermo-mechanical aging.

MATERIAL AND METHODS

Sixty conical connection implants (4.3 mm-diameter) were divided in five groups (n = 12): PFM using gold abutment (GAbut-PFM), lithium disilicate crown bonded to customized titanium abutment (TAbut+LDS), lithium disilicate abutment-crown bonded to titanium base (TiBase+LDS), zirconia abutment-crown bonded to titanium base (TiBase+ZR), polymer-infiltrated ceramic-network (PICN) abutment-crown bonded to titanium base (TiBase+PICN). Simultaneous thermocycling (5°-55°C) and chewing simulation (1,200,000-cycles, 49 N, 1.67 Hz) were applied. Catastrophic and non-catastrophic events were evaluated under light microscope, and survival and complication rates were calculated. Specimens that survived aging were loaded until failure and bending moments were calculated.

RESULTS

Survival rates after aging were 100% (TAbut+LDS, TiBase+LDS), 91.7% (GA-PFM), 66.7% (TiBase+ZR) and 58.3% (TiBase+PICN) and differed among the groups (p = .006). Non-catastrophic events as screw loosening (GA-PFM) and loss of retention or micro-/macro-movement (TiBase groups) were observed. Complication rates varied among the groups (p < .001). TiBase+PICN had lower bending moment than all the other groups (p < .001).

CONCLUSIONS

Hybrid abutment-crowns made of lithium disilicate can be an alternative to PFM-based restorations, although concerns regarding the bonded interface between the titanium base and abutment-crown can be raised. PICN and zirconia may not be recommended due to its inferior mechanical and bonding outcomes, respectively. Titanium customized abutment with bonded lithium disilicate crown appears to be the most stable combination.

Resin-matrix ceramics for occlusal veneers: Effect of thickness on reliability and stress distribution

OBJECTIVE

To evaluate the influence of resin-matrix ceramic material and thickness on reliability and stress distribution of occlusal veneers (OV).

METHODS

One hundred and twenty-six OV of a mandibular first molar were milled using a CAD/CAM system and allocated according to materials (resin nanoceramic (RNC) or polymer-infiltrated ceramic network (PICN)) and thicknesses (0.5, 1.0 and 1.5 mm), totaling six groups (RNC0.5, RNC1, RNC1.5, PICN0.5, PICN1, and PICN1.5). Step-stress accelerated-life testing was performed (n = 21/group) with the load applied at the distobuccal cusp tip of the occlusal veneer until failure or suspension. The use level probability Weibull curves and reliability were calculated and plotted (90% CI). Finite element analysis evaluated the stress distribution according to maximum principal stress (σ_max) on the restoration and maximum shear stress (τ_max) on the cement layer.

RESULTS

There was no difference in the probability of survival for the estimated missions among the groups, except at 600 N in which the results were significantly lower to PICN1.5 (6%) compared to RNC1 (55%) and RNC1.5 (60%). The σ_max values were higher for PICN (31.85-48.63 MPa) than RNC (30.78-33.09 MPa) in the same thicknesses. In addition, 0.5 mm groups concentrated more stress in the restoration (33.09-48.63 MPa) than 1.0 mm (31.11-35.36 MPa) and 1.5 mm (30.78-31.85 MPa) groups in the same material.

SIGNIFICANCE

Both resin-matrix ceramic materials seem up-and-coming restorative systems for occlusal veneers irrespective of the thicknesses as a consequence of the high reliability.

Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols

The effect of various pretreatments on the bonding of a resin cement to resin-composite CAD/CAM blocks (RCBs) was examined. The surface of dispersed-filler RCBs (DF-RCBs) and a polymer infiltrated ceramic network RCB (PICN-RCB) was roughened using hydrofluoric acid etching (HF) or sandblasting, and followed by silanization and/or universal adhesive (UA) application. Microtensile bond strength (µTBS), surface roughness parameters (arithmetical mean height (Sa); developed interfacial area ratio (Sdr)), and critical surface energy (γ_c) were determined. For most DF-RCBs, the highest µTBS was obtained using HF+UA. UA application to DF-RCBs resulted in similar or higher µTBS compared to silanization, which indicates that silane treatment is not crucial for DF-RCBs, especially after HF. In contrast, the highest µTBS to PICN-RCB was obtained with silanization. Both roughening pretreatments significantly increased the surface roughness parameters and the γ_c of all RCBs. The γ_c was positively correlated with Sa (r=0.756, p<0.001) and Sdr (r=0.837, p<0.001).

Effect of different preparation designs and all ceramic materials on fracture strength of molar endocrowns

Objective:

The aim was to compare the fracture strength of Molar endocrowns fabricated from different all-ceramic materials and various preparation designs.

Materials and methods:

Ninety extracted human molar teeth were root canal treated and randomly divided into three groups according to the all ceramic materials used for fabrication of the endocrowns ( n = 30): (1) Lithium disilicate (IPS e.max Press); (2) Polymer infiltrated ceramic (Vita Enamic); (3) High translucency zirconia (Ceramill Zolid HT). Each group was subdivided into 3 subgroups ( n = 10) according to the preparation design as 2 mm occlusal reduction, 4.5 mm occlusal reduction, and 4.5 mm occlusal reduction with 2 mm radicular extension. The endocrowns from each material were fabricated and surface treated according to the manufacturer’s recommendations. After cementation with self-adhesive resin luting cement, the specimens were stored in a humid environment for 72 hours and subsequently subjected to 5000 thermal cycles. After, a compressive, static-axial load was applied using a universal testing machine until failure. Load-to-failure was recorded (N) and the specimens were examined under a stereomicroscope to determine the failure type. The data was statistically analyzed using One-way ANOVA and Tukey HSD tests at p < 0.05.

Results:

The Lithium Disilicate endocrowns recorded the higher mean fracture strength for 4.5 mm occlusal thickness and 2 mm radicular extension at 3770.28 N and 3877.40 correspondingly. The High translucency zirconia endocrowns at conventional 2 mm thickness showed the highest mean fracture load (3533.34 N). Even though polymer infiltrated ceramic endocrowns displayed comparatively lesser fracture load; they recorded the predominantly favorable fractures.

Conclusions:

Increased occlusal thickness showed a significant improvement in fracture strength of lithium disilicate and polymer infiltrated ceramic molar endocrowns. Although the 2 mm radicular extension had the substantial enhancement of fracture strength in high translucency zirconia, it resulted in more unfavorable failure types.

Monitoring fatigue damage in different CAD/CAM materials: A new approach with optical coherence tomography

PURPOSE

To investigate fatigue damage over time, monolithic posterior computer-aided-designed/computer-aided-manufactured (CAD/CAM) crowns were artificially aged in a mouth-motion-simulator, and damage was monitored with optical coherence tomography (OCT).

METHODS

Forty-eight crowns were milled of six different CAD/CAM-materials (n=8), including 3Y-TZP (Lava Plus,'3Y'), 4Y-PSZ (Pritidentamultidisc,'4Y'), 5Y-PSZ (Prettauanterior,'5Y'), zirconia-reinforced lithium silicate (CeltraDuo,'ZLS'), hybrid ceramic (Vita Enamic,'VE'),and resin composite (BrilliantCrios,'COM'), and were adhesively luted on CAD/CAM-milled human molars. Specimens were artificially aged in a mouth-motion-simulator (50-500N, 2Hz, 37°C) for a period of 1 million cycles. Before loading and every 250,000 cycles, the specimens were investigated with spectral domain (SD)-OCT (RS-3000). The maximum vertical and horizontal damage were measured with imaging-processing-software (ImageJ). After testing, the specimens were sliced and analysed via light microscope (Zeiss) to compare the new OCT method with the established light microscope method. Data were subjected to ANCOVA and 2x4-ANOVA.

RESULTS

No failure occurred during mouth-motion-simulation. However, all specimens (except for 3Y and 4Y) showed fatigue damage. There was a significant difference in the maximum damage between the CAD/CAM-materials (p<.05). ZLS exhibited the highest damage, followed by VE, COM and 5Y. While damage associated with 5Y was initially noticed after 750,000 cycles, all other materials already showed crack formation after 250,000 cycles. Furthermore, a linear increase in damage over time was noticed in all materials. Due to the shallow light penetration of OCT, damage in the outer area could only be visualized with light microscope.

CONCLUSIONS

OCT is feasible for monitoring fatigue damage over time within different CAD/CAM-materials, particularly for subsurface damages.

Response of two gingival cell lines to CAD/CAM composite blocks

OBJECTIVE

This study aimed to investigate the influence of CAD/CAM composite materials on human gingival fibroblasts (HGF) and gingival keratinocytes (HGK).

METHODS

Four materials were investigated: two resin-composite blocks (RCB), Grandio Blocs (GR) and Block HC (HC); one polymer-infiltrated ceramic network (PICN) (Enamic, EN); and one conventional resin-composite, Grandioso (GND). HGF and HGK were cultured as per the supplier's protocol (ATCC, UK). Cell proliferation and cytotoxicity were evaluated at 1, 3, 5 and 10 days using LDH and Alamar Blue assays. Indirect immunostaining was used to assess the Caspase-3 activity. Data were analysed via two-way ANOVA, one-way ANOVA and Tukey's post hoc test (α = 0.05 for all tests).

RESULTS

There was significant difference in cell proliferation of the HGK and HGF cells in contact with different composite materials but no significant differences in their cytotoxicity. There was a significant effect on cell proliferation and cytotoxicity with different exposure times, for each type of resin-composite. HGF cell proliferation was higher than HGK with almost all investigated materials and at all time points. No Caspase-3 activity was detected in either cell lines.

SIGNIFICANCE

HGK proliferation and cytotoxicity appeared to be more influenced by composite materials compared to HGF, demonstrating EN cytotoxic effects in HGK. Different manufacturing techniques of resin-composites (photo curing versus heat/pressure curing) had no significant effect on their biocompatibility.

Influence of Occlusal Thickness and Radicular Extension on the Fracture Resistance of Premolar Endocrowns from Different All-Ceramic Materials

Endocrowns are primarily recommended in a molar region with a standardized preparation design. The aim of the study was to evaluate the effect of different occlusal preparation depths, pulp chamber-radicular extension, and all-ceramic materials on the fracture resistance of premolar endocrowns. Ninety human premolar teeth were root canal treated, randomly divided into three main groups according to all-ceramic material used for fabrication as Lithium Disilicate (LD) ceramic, Polymer infiltrated ceramic (PIC) and High translucency zirconia (HTZ). They were further subdivided into three subgroups (n = 10) according to preparation design of 2 mm occlusal reduction, 4.5 mm occlusal reduction and 4.5 mm occlusal reduction with 2 mm radicular extension. The endocrowns from respective restorative materials were fabricated, surface conditioned, and cemented with self-adhesive resin cement. All samples were thermocycled for 5000 cycles and subjected to compressive static load at 45° angluation with the cross-head speed of 0.5 mm/minute until the fracture. The mean fracture resistance of LD ceramic at 2 mm, 4.5 mm thickness and radicular extension was 62.55 MPa, 45.80 MPa, 74.27 MPa respectively. The corresponding values for the PIC and HTZ ceramics were 26.30 MPa, 21.65 MPa, 25.66 Mpa and 23.47 MPa, 27.30 MPa, 37.29 MPa respectively. The LD ceramic and greater extension inside the pulp chamber had higher fracture resistance.

Microleakage of thin-walled monolithic zirconia and polymer-containing CAD-CAM crowns

STATEMENT OF PROBLEM

Monolithic restorations facilitate computer-aided design and computer-aided manufacturing (CAD-CAM) processability and provide thin-walled restorations, which require less tooth reduction. For the long-term success of these restorations, their durable sealing is important. However, data in this regard are sparse.

PURPOSE

The purpose of this in vitro study was to investigate the microleakage of monolithic complete crowns made from current CAD-CAM materials after mastication simulation.

MATERIAL AND METHODS

Sixty-four identical test specimens (crown and tooth) were milled based on corresponding standard tessellation language data sets: one for the crowns and another for the human molar teeth. Four CAD-CAM restoration materials were investigated: 2 polymer-containing materials, Brilliant Crios (BC) and Vita Enamic (VE), and 2 zirconia materials, ultra-high-translucent Nacera Pearl Q³ Multi-Shade (ultraHT) and high-translucent Nacera Pearl Multi-Shade (HT). The crowns were adhesively luted to the CAD-CAM milled human molars with 1 of 3 luting systems: OneCoat7Universal and DuoCem (BC); A.R.T.Bond and DuoCement (VE); or EDPrimer/Panavia F2.0 (ultraHT and HT). The specimens were divided in 2 subgroups, and 2 different mastication simulations were applied: normal function (NF) and bruxism (B). A dye penetration test was used to detect microleakage, and the specimens were sectioned. A digital microscope (Zeiss) was used for analysis and to calculate the percentage of leakage in relation to the height of the tooth. Data were subjected to the Mann-Whitney and Kruskal-Wallis tests (α=.05).

RESULTS

Microleakage was identified in all groups. VE reported the highest leakage with a mean of 13.0%, followed by ultraHT (4.8%), HT (3.6%), and BC (3.0%). No significant difference was detected between the 2 simulation programs (normal function and bruxism). However, VE and the zirconia group HT exhibited a significant difference (P<.014), whereas no significant difference was noted among the zirconia groups or the polymer-containing groups BC and VE.

CONCLUSIONS

Thin-walled restorations made of CAD-CAM composite resin and zirconia exhibited reduced microleakage compared with the polymer-containing ceramic. Thus, from the specific viewpoint of microleakage, CAD-CAM composite resins and zirconia seem to be suitable materials for thin-walled complete crowns.

Sliding contact wear and subsurface damage of CAD/CAM materials against zirconia

OBJECTIVE

Most previous work conducted on the wear behavior of dental materials has focused on wear rates and surface damage. There is, however, scarce information regarding the subsurface damage arising from sliding contact fatigue. The aim of this study was to elucidate the wear mechanisms and the subsurface damage generated during sliding contact fatigue in 5 contemporary CAD/CAM materials against a zirconia indenter.

METHODS

Forty discs (Ø12mm, 1.55mm thick) were cut out of IPS e.max CAD (e.CAD), Suprinity PC (SUP), Enamic (ENA), Vitablocs Mark II (VMII) and Lava Ultimate (LU) blocks and mirror polished. After cementation onto a dentin-like composite, off-axis mouth-motion cycling was conducted with a spherical zirconia indenter (r=3.18mm) in water (200N load, 2Hz frequency) for 5 different cycling periods (10², 10³, 10⁴, 10⁵, 10⁶ cycles, n=8). Analysis of the wear scars was conducted using light-microscopy, scanning-electron-microscopy and optical profilometry. Subsurface damage was assessed using sagittal and transverse sections of the samples.

RESULTS

Fatigue wear mechanisms predominated in glassy materials (e.CAD, SUP, VMII), accompanied by extensive subsurface damage, whereas abrasive wear mechanisms were responsible for the large wear craters in the resin composite (LU) with an absolute absence of subsurface fracture. A combination of both mechanisms was observed in the polymer-infiltrated reinforced-glass (ENA), displaying large wear craters and severe subsurface damage.

SIGNIFICANCE

Well-controlled laboratory simulation can identify wear and subsurface damage susceptibility of various classes of restorative materials. Both wear and subsurface fracture are determining factors for the long-term success of restorations.

Nature-Inspired Nacre-Like Composites Combining Human Tooth-Matching Elasticity and Hardness with Exceptional Damage Tolerance

Making replacements for the human body similar to natural tissue offers significant advantages but remains a key challenge. This is pertinent for synthetic dental materials, which rarely reproduce the actual properties of human teeth and generally demonstrate relatively poor damage tolerance. Here new bioinspired ceramic-polymer composites with nacre-mimetic lamellar and brick-and-mortar architectures are reported, which resemble, respectively, human dentin and enamel in hardness, stiffness, and strength and exhibit exceptional fracture toughness. These composites are additionally distinguished by outstanding machinability, energy-dissipating capability under cyclic loading, and diminished abrasion to antagonist teeth. The underlying design principles and toughening mechanisms of these materials are elucidated in terms of their distinct architectures. It is demonstrated that these composites are promising candidates for dental applications, such as new-generation tooth replacements. Finally, it is believed that this notion of bioinspired design of new materials with unprecedented biologically comparable properties can be extended to a wide range of material systems for improved mechanical performance.

Bonding to industrial indirect composite blocks: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the effect of surface conditioning methods on the bond strength of industrial indirect composite blocks (ICs).

METHODS

Based on the PICOS strategy, the Medline via PubMed, Embase and Web of Science (ISI - Web of Knowledge) electronic databases were searched for peer-reviewed articles in both English and Chinese, with no publication year limit. In vitro studies evaluating the effects of surface conditioning on the bond strength of ICs were selected. The meta-analysis was conducted to calculate the mean difference between surface-conditioned ICs and unconditioned controls. Subgroup analysis was performed to evaluate the different surface conditioning methods, separately for polymer-infiltrated ceramic network (PICN) material and the ICs with dispersed fillers (ICDFs). Meta-analyses were performed with a random-effects model at a significance level of 0.05.

RESULTS AND SIGNIFICANCE

From 802 relevant studies, 25 were selected for full-text analysis. Nineteen studies were eligible for inclusion in this systematic review, whereas 9 studies were included in the meta-analysis. A manual search of the principal periodicals specific to the area resulted in no additional articles. The meta-analysis indicated a significant difference in bond strength between the surface-conditioned ICs and controls under both non-aged and aged conditions. The combination of mechanical and chemical conditioning yielded the highest bond strength of ICs. This meta-analysis suggests that chemical etching followed by a universal primer and alumina air abrasion followed by a silane coupling agent could be considered the best strategy for optimizing the bond strength of PICN materials and ICDFs under aged conditions, respectively.