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Yıldız P, Güneş Ünlü D, Aydoğdu HM. Evaluation of vertical marginal discrepancy and load-to-failure of monolithic zirconia and lithium disilicate laminate veneers manufactured in different thicknesses. BMC Oral Health 2024; 24:913. [PMID: 39118080 PMCID: PMC11312385 DOI: 10.1186/s12903-024-04685-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate the feasibility of monolithic zirconia laminate veneers (MZLV) compared to lithium disilicate laminate veneers (LDLV). MATERIALS AND METHODS Sixty resin replicas, each prepared with depths of 0.5 mm, 0.7 mm, and 1 mm, were produced using a 3D printer from acrylic teeth. Laminate veneers of these thicknesses were milled from pre-sintered monolithic zirconia (3rd generation) and lithium disilicate blocks. The intaglio surface of MZLV was treated with air abrasion using 110 μm diameter silica-modified aluminium oxide particles and ceramic primer, while LDLV was etched with etchant gel and treated with the ceramic primer before cementation with resin cement. Vertical marginal discrepancy (VMD) was assessed using a stereomicroscope, and a load-to-failure test was conducted using a universal testing machine. Failure modes were evaluated macroscopically on fractured surfaces. Data were analysed statistically using Two-way ANOVA and Bonferroni correction (α = 0.05). RESULTS LDLV samples exhibited significantly larger VMD compared to MZLV samples across all thicknesses, especially in cervical, palatal, and mean data. Within the LDLV group, load-to-fracture values for 0.7 mm and 1.0 mm thicknesses were similar, whereas for 0.5 mm thickness, it was significantly lower. In the MZLV group, load-to-fracture values were lower for 0.7 mm and 1.0 mm thicknesses compared to LDLV, but higher for 0.5 mm thickness. CONCLUSIONS Material choice and restoration thickness significantly influence laminate veneer restorations' success. MZLV generally exhibits superior vertical marginal fit compared to LDLV, with varying load-to-failure values across different thicknesses. Clinical management of debonding in MZLV is simpler compared to restoration fracture in LDLV. CLINICAL RELEVANCE Considering clinical factors, MZLV may be a preferable option to LDLV for this restoration with the thickness of 0.5 mm.
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Affiliation(s)
- Pınar Yıldız
- Department of Prosthodontic Dentistry, Nimet Bayraktar Oral and Dental Health Center, Kayseri, Turkey.
| | - Damla Güneş Ünlü
- Faculty of Dentistry, Department of Prosthetic Dentistry, Nuh Naci Yazgan University, Kayseri, Turkey
| | - Hasan Murat Aydoğdu
- Faculty of Dentistry, Department of Prosthetic Dentistry, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
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Yousry M, Hammad I, El Halawani M, Aboushelib M. Randomized clinical trial of zirconia laminate veneers sintered by using conventional versus speed process: 1-year follow-up. J Prosthet Dent 2024:S0022-3913(24)00352-4. [PMID: 38824110 DOI: 10.1016/j.prosdent.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 06/03/2024]
Abstract
STATEMENT OF PROBLEM The application of highly translucent multilayered zirconia ceramic in minimally invasive esthetic dentistry allows the achievement of both esthetics and strength with minimal thickness. Clinical studies that have assessed the performance of zirconia ultrathin veneers sintered with the conventional and speed procedure are lacking. PURPOSE The purpose of this clinical study was to evaluate the effect of speed sintering processes on the translucency and clinical performance of zirconia laminate veneers. MATERIAL AND METHODS Four participants had their teeth restored with 32 ultratranslucent zirconia laminate veneers. Based on the zirconia sintering procedure, the participants were randomly allocated into 2 groups. The teeth were prepared by selective reduction over trial restorations. Zirconia veneers were milled from multilayer zirconia blanks and sintered either by speed sintering or conventional sintering as specified by the manufacturer's recommendations. The intaglio surface of the veneers were airborne-particle abraded with 50-μm aluminum-oxide, and the veneers were then adhesively bonded to the teeth with translucent light-polymerizing resin cement. The modified California Dental Association (CDA)/Ryge criteria were used to assess participants at baseline and every 3 months for 12 months. The translucency and the color difference of the tooth before and after veneer restoration were evaluated. For statistical analysis, the Pearson chi squared test, independent t test, and paired t test were used (α=.05). RESULTS Translucency and color differences were significantly higher in the conventionally sintered group (P<.05). No restorations were lost. No significant differences were found between the 2 groups in the CDA/Ryge criteria or color parameter after follow-up intervals (P>.05). The primary qualitative changes observed at the final recall were marginal integrity and marginal discoloration. The color match and zirconia surface were rated Alfa. CONCLUSIONS After 1 year of follow-up, both conventional and speed sintered ultrathin zirconia laminates showed satisfactory functional, esthetic, and color stability outcomes.
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Affiliation(s)
- Mahinour Yousry
- PhD Researcher, Division of Fixed Prosthodontics, Department of Conservative Dentistry, Faculty of Dentistry, Alexandria University, Alexandria, Egypt.
| | - Ihab Hammad
- Professor, Division of Fixed Prosthodontics, Department of Conservative Dentistry, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Mohamed El Halawani
- Lecturer, Division of Fixed Prosthodontics, Department of Conservative Dentistry, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Moustafa Aboushelib
- Professor, Department of Dental Materials Science, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
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Aydoğdu HM, Yıldız P, Ünlü DG. A comparative study of translucency and color perception in monolithic zirconia and lithium disilicate veneers. Heliyon 2024; 10:e23789. [PMID: 38192772 PMCID: PMC10772169 DOI: 10.1016/j.heliyon.2023.e23789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/02/2023] [Accepted: 12/13/2023] [Indexed: 01/10/2024] Open
Abstract
Ceramic laminate veneers which are a conservative approach to restoring anterior teeth, combining minimal preparation and esthetics. This study aims to evaluate the impact of the thickness of monolithic zirconia laminate veneers on their optical properties and color perception, comparing them to lithium disilicate. A total of 60 laminate veneers were prepared using two ceramic materials, divided into three groups for each material (n = 10) with thicknesses of 0.5, 0.7, and 1.0 mm. CIELab color parameters of the veneers were measured using a spectrophotometer and translucency parameters were calculated. The veneers were cemented onto uniform dies and final L, a, b values of the restorations were measured. The color difference between the different thicknesses was calculated using the CIEDE2000 formula. Two-way ANOVA and Bonferroni HSD post hoc tests were conducted to compare the color parameters (α = 0.05). The results showed that both material type (p < 0.001) and thickness (p < 0.001) influenced translucency values. The translucency values of zirconia veneers were significantly lower than those of lithium disilicate. The color differences (ΔE00) resulting from thickness changes (0.5-1.0 mm) were near or below the perception threshold for lithium disilicate, but distinct for zirconia restorations. In conclusion, monolithic zirconia veneers demonstrated lower translucency compared to lithium disilicate. Changing the material thickness affected the translucency of both materials, but not the color perception only for zirconia.
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Affiliation(s)
- Hasan Murat Aydoğdu
- Department of Prosthodontics, Çanakkale Onsekiz Mart University Faculty of Dentistry, Çanakkale, Turkiye
| | - Pınar Yıldız
- Ministry of Health Nimet Bayraktar Oral and Dental Health Hospital, Kayseri, Turkiye
| | - Damla Güneş Ünlü
- Department of Prosthodontics, Nuh Naci Yazgan University Faculty of Dentistry, Kayseri, Turkiye
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Baig MR, Qasim SSB, Baskaradoss JK. Marginal and internal fit of porcelain laminate veneers: A systematic review and meta-analysis. J Prosthet Dent 2024; 131:13-24. [PMID: 35260253 DOI: 10.1016/j.prosdent.2022.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/01/2022] [Accepted: 01/04/2022] [Indexed: 11/22/2022]
Abstract
STATEMENT OF PROBLEM Marginal integrity and internal adaptation are key to the long-term success of porcelain laminate veneers. Evidence for their marginal and internal fit is unclear, and the factors affecting such fit have not been identified. PURPOSE The purpose of this systematic review and meta-analysis was to summarize the scientific literature assessing the effects of various parameters on the marginal and internal fit of porcelain laminate veneers. MATERIAL AND METHODS An electronic search was conducted to identify all relevant published articles on the fit accuracy of ceramic veneers between January 2000 and June 2021 in the PubMed-MEDLINE, Scopus, Embase, Google Scholar, and Web of Science databases. Information, including the study outcomes, in terms of the mean marginal gap, internal gap, and absolute marginal discrepancies of porcelain laminate veneers, was extracted from the selected studies. The inverse-variance random effects model was used to analyze the pooled results and estimate the overall effect based on the heterogeneity of studies (α=.05). RESULTS Twenty-one studies were selected for analysis, 2 clinical and 19 in vitro. The risk of bias was "medium" for most studies (19 of 21), and only 2 studies were classified as "high risk." A mean difference of -4.53 μm (95% CI: -21.46 to 12.41) was found, with no statistically significant difference in marginal gap between the pressed and milled fabrication modes (P=.600). As for the internal gap, significant differences were found (mean difference=-40.56 μm; 95% CI: -76.54 to -4.58), with pressed veneers performing better (P=.030). Butt joint preparation design produced significantly (P=.002) lower marginal gaps than the palatal chamfer (mean difference=-14.02 μm; 95% CI: -23.07 to -4.98). CONCLUSIONS No significant differences were found between the pressed and milled porcelain laminate veneers for marginal gap, but for the internal gap, the differences were significantly in favor of the pressed type. The butt joint veneer preparation design was significantly better than the palatal chamfer design in terms of marginal fit.
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Affiliation(s)
- Mirza Rustum Baig
- Associate Professor, Department of Restorative Sciences (Prosthodontics), Faculty of Dentistry, Kuwait University, Kuwait City, Kuwait.
| | - Sayed Saad Bin Qasim
- Assistant Professor, Department of Bioclinical Sciences (Dental Materials), Faculty of Dentistry, Kuwait University, Kuwait City, Kuwait
| | - Jagan Kumar Baskaradoss
- Assistant Professor, Department of Developmental and Preventive Sciences (Dental Public Health), Faculty of Dentistry, Kuwait University, Kuwait City, Kuwait
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Erdinç G, Bülbül M, Özcan M. Fracture strength and energy-dispersive spectroscopy analysis of 3-unit fixed partial dentures fabricated from different monolithic zirconia materials. J Prosthet Dent 2023:S0022-3913(23)00178-6. [PMID: 37024356 DOI: 10.1016/j.prosdent.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/08/2023]
Abstract
STATEMENT OF PROBLEM Mastication forces in different regions affect the survival of multiunit posterior restorations. The fracture strength of 3-unit posterior monolithic zirconia fixed partial dentures (FPDs) and their fracture patterns require investigation. PURPOSE The purpose of this in vitro study was to evaluate and compare the fracture strength and fracture pattern of 3-unit posterior FPDs fabricated from different monolithic zirconia materials. MATERIAL AND METHODS Thirty 3-unit FPDs were fabricated from BruxZir, FireZr, and Upcera (n=10 per group). Energy-dispersive spectroscopy analysis was performed on 2 selected specimens from each group. All specimens were exposed to a mastication simulator for 1.2×106 cycles and then monotonically loaded to fracture at a crosshead speed of 1 mm/min. The surfaces of a selected fractured specimen were examined at magnifications of ×25 and ×500 with scanning electron microscopy. Conformity to normal distribution was evaluated with the Shapiro-Wilk test. One-way analysis of variance was used to compare the normally distributed initial crack formation load F initial (Fi) and catastrophic failure strength F maximum (Fm) means by group. Weibull statistics were calculated by using the maximum likelihood estimation method. The chi-square test was used to compare shape and scale parameters (α=.05). RESULTS The mean Fm values were fail1878.9 N for Upcera, 2177.8 N for BruxZir, and 2229.4 N for FireZr. Upcera and BruxZir showed statistically significant differences for the Fm mean values (P=.039). The differences between the fracture type distributions according to the groups were statistically similar (P>.05). For Fi, Upcera presented the highest Weibull modulus value (2.199), FireZr had the lowest (1.594), while for Fm, BruxZir had the highest Weibull modulus value (9.267) and FireZr the lowest (6.572). CONCLUSIONS Using the zirconia materials BruxZir, FireZr, and Upcera resulted in high Fm values after aging procedures. With all materials, the fractures were most commonly found in the connector areas in the tested FPDs.
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Affiliation(s)
- Gülbahar Erdinç
- Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Karabük University, Karabük, Turkey.
| | - Mehmet Bülbül
- Professor, Department of Prosthodontics, Faculty of Dentistry, İstanbul Aydin University, İstanbul, Turkey
| | - Mutlu Özcan
- Professor and Head, Division of Dental Biomaterials, Clinic for Reconstructive Dentistry, Center for Dental and Oral Medicine, University of Zurich, Zurich, Switzerland
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Marginal Fit of Porcelain Laminate Veneer Materials under Thermocycling Condition: An In-Vitro Study. Dent J (Basel) 2023; 11:dj11010012. [PMID: 36661549 PMCID: PMC9858300 DOI: 10.3390/dj11010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Objective: The purpose of this study was to evaluate the cervical marginal fit of porcelain laminate veneer (PLV) restorations made from two different types of CAD/CAM ceramic laminates: CEREC C PC and E.max (LD). Materials and Methods: This in-vitro experiment used a total of 32 human maxillary first premolars that were clean and free of any cracks or caries, extracted for orthodontic purposes. The samples were divided in a random way into two study groups: A and B (n = 16). Each sample was mounted on a dental surveyor and a silicon impression was made to create a silicone index for each tooth in both groups. Standardized preparation was carried out for all the samples by using preparation bur kit for the ceramic veneer system. Subsequently, digital impressions were made for all the samples by using Trios 3 shape intraoral camera (Sirona Dental Systems). The design of veneer restorations was made using Sirona inLab CAD SW 16.1 with CEREC inLab MC XL (Dentsply, Sirona Dental Systems, Bensheim, Germany). The veneer restorations were cemented using 3M RelyX veneer resin cement (3M ESPE, Seefeld, Germany) and the samples kept in distilled water for two weeks at 37 °C. All the specimens were subjected to thermocycling in a water bath with temperature varying between 5 °C and 55 °C for 500 cycles. The cervical marginal fit of veneers was evaluated by a digital microscope after sectioning the embedded teeth in acrylic resin. Results: The lowest mean of cervical marginal gap was recorded for Group A (91.59431 ± 1.626069) which was restored with CEREC CAD/CAM veneers, while the highest mean value of the gap was recorded for Group B (106.48863 ± 2.506684) which was restored with IPS E.max CAD. The t-test showed that the type of porcelain veneer restoration had a highly significant effect on the cervical marginal fit (p ≤ 0.01). Conclusions: CEREC CAD/CAM veneers showed smaller cervical marginal gaps, indicating a better fit compared to the IPS E.max CAD.
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Malallah AD, Hasan NH. Thickness and yttria percentage influences the fracture resistance of laminate veneer zirconia restorations. Clin Exp Dent Res 2022; 8:1413-1420. [PMID: 36099336 PMCID: PMC9760162 DOI: 10.1002/cre2.658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 08/14/2022] [Accepted: 08/18/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Mechanical properties are cardinal for the long-term clinical success of laminate veneer restorations but the selection of new restorative materials should ideally be based on clinical evidence, therefore, in vitro testing of dental materials is a good alternative to evaluate their properties and understand their behavior so this study aimed to compare and evaluate the effect of two different thicknesses and yttria percentage on the fracture resistance of laminate veneer zirconia restorations. MATERIALS AND METHODS Forty laminate veneer restoration prepared from partial sintering zirconia of 3Y (yttria), 5Y (yttria), combined 3Y&5Y (yttria), and lithium disilicate. Specimens were assigned into four main groups according to their percentage of yttria content (n = 10) and subgrouped into two thicknesses (0.5 mm thickness and 0.3 mm thickness) (n = 5) as follows: Group I, II, III, and IV (Group I for lithium disilicate (control), Group II for 3Y zirconia, Group III for 5Y zirconia, and Group IV for combined 3Y&5Y zirconia), each of them subdivided according to their thickness into two subgroups (n = 5 for each one) and resistance to fracture for each restoration was evaluated using a universal testing machine. Data were analyzed using a one-way analysis of variance and Duncan's tests at a 5% level of significance. RESULTS The thickness of laminate veneer restoration significantly affects the fracture resistance value of all type of laminate veneers restorations (fracture resistance mean value was highest for 0.5 mm thickness and lower for 0.3 mm thickness restorations) and yttria percentage significantly affect fracture resistance value of zirconia laminate veneer restorations (fracture resistance mean value was highest for 0.5 mm thickness of 3Y zirconia [865 N] and combined 3Y&5Y zirconia [846 N]). CONCLUSIONS Reducing the thickness of laminate zirconia veneer restorations to 0.3 mm reduces its fracture resistance and increasing yttria percentage had an adverse effect on fracture resistance of zirconia laminate veneer restorations.
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Affiliation(s)
- Ali Dhahee Malallah
- Department of Conservative Dentistry, College of DentistryUniversity of MosulMosulIraq
| | - Nadia H. Hasan
- Department of Conservative Dentistry, College of DentistryUniversity of MosulMosulIraq
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Dentin Exposure after Tooth Preparation for Laminate Veneers: A Microscopical Analysis to Evaluate the Influence of Operators' Expertise. MATERIALS 2022; 15:ma15051763. [PMID: 35268994 PMCID: PMC8911512 DOI: 10.3390/ma15051763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/02/2022] [Accepted: 02/24/2022] [Indexed: 12/05/2022]
Abstract
Background: To assess the quantity of dentin exposure detected by 3 operators with different clinical expertise for 2 designs of tooth preparation for laminate veneers: window (WI) and butt joint (BJ). Methods: 20 intact maxillary central incisors were collected and then prepared for laminate veneers to a depth of 0.6 mm, with a cervical mini-chamfer finish line of 0.3 mm. Each prepared tooth was analyzed by 3 operators with different expertise: undergraduate student (ST), general practitioner (GP), and prosthodontist (PR), at sight under magnification. Besides descriptive statistics (CI 95%), 2-way ANOVA and Games−Howell tests were used to analyze differences among groups (α = 0.05). Results: The means of percentage and area of detected dentin exposure were WI = 30.48%, 21.57 mm2; BJ = 30.99%, 21.97 mm2; ST/WI = 22.82%, 16.44 mm2; GP/WI = 58.05%, 40.64 mm2; PR/WI = 10.55%, 7.63 mm2; ST/BJ = 28.99%, 20.83 mm2; GP/BJ = 40.56%, 28.32 mm2; PR/BJ = 23.42%, 16.75 mm2. Significant differences were found between ST/WI vs. GP/WI (p = 0.005) and GP/WI vs. PR/WI (p < 0.001). Conclusions: There was no difference in detection of exposed dentin among operators with different expertise for BJ preparation, whereas differences were found between the general practitioner and the other 2 operators in WI. Moreover, the quantity of exposed dentin was not related to different tooth preparation designs.
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Baig MR, Akbar AA, Sabti MY, Behbehani Z. Evaluation of Marginal and Internal Fit of a CAD/CAM Monolithic Zirconia-Reinforced Lithium Silicate Porcelain Laminate Veneer System. J Prosthodont 2021; 31:502-511. [PMID: 34608712 DOI: 10.1111/jopr.13438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the marginal and internal fit of monolithic computer-aided design/computer-aided manufacturing (CAD/CAM) ZLS (Vita Suprinity) glass ceramic porcelain laminate veneers (PLVs), in terms of marginal and internal gap widths, in comparison to monolithic lithium disilicate (LDS) [IPS e.max CAD] CAD/CAM veneers, and, also, to analyze the effect of incisal preparation designs (butt joint and chamfer), on the marginal and internal fit accuracy. MATERIALS AND METHODS Forty dental stone dies poured from impressions made of two master metal dies with different incisal preparation designs were scanned to produce digital models. Forty ceramic veneers were designed and milled using the virtual models-10 ZLS butt joint, 10 ZLS chamfer, 10 LDS butt joint, and 10 LDS chamfer. The monolithic ceramic veneers produced were then subjected to marginal and internal gap width evaluation using X-ray nano-computed tomography and computerized digital analysis (n = 10). Descriptive analyses of data were performed and the influence of "material" and "preparation design" on the marginal and internal fit of veneers was assessed using 2-way ANOVA (α = 0.05). Bonferroni post-hoc multiple comparison tests were used to further analyze the interactions between the material and preparation design after adjusting the α value by Holm-Bonferroni method (α = 0.01). RESULTS Mean marginal and internal gaps for ZLS PLVs were 65 ±11 μm and 112 ±14 μm for butt joint, and 100 ±24 μm and 100 ±21 μm for chamfer, respectively. Corresponding values for LDS PLVs were 78 ±25 μm and 114 ±17 μm for butt joint, and 104 ±18 μm and 106 ±7 μm for chamfer. Marginal gap and internal gap differences between ZLS and LDS PLVs were not significant (marginal gap: F = 1.786, p = 0.190; internal gap: F = 0.807, p = 0.375). However, the preparation designs (butt joint and chamfer) differed significantly in terms of marginal gaps (F = 23.797, p = 0.000), but not internal gaps (F = 3.703; p = 0.059). CONCLUSIONS Butt joint margins produced better marginal accuracy in terms of marginal gap, compared to chamfers, for ZLS CAD/CAM laminate veneers.
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Affiliation(s)
- Mirza Rustum Baig
- Department of Restorative Sciences (Prosthodontics), Faculty of Dentistry, Kuwait University, Kuwait City, Kuwait
| | - Aqdar A Akbar
- Department of General Dental Practice, Faculty of Dentistry, Kuwait University, Kuwait City, Kuwait
| | - Mohammad Y Sabti
- Department of General Dental Practice, Faculty of Dentistry, Kuwait University, Kuwait City, Kuwait
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