Influence of preparation design on fracture resistance of different monolithic zirconia crowns: A comparative study

Evaluation of zirconia crowns restoring endodontically treated posterior teeth with 2 finish line designs and 2 occlusal reduction schemes: A randomized clinical trial

STATEMENT OF PROBLEM

Preparation design has been linked to restoration survival, and the finish line geometry, such as a deep chamfer or shoulder, has been linked to marginal integrity. However, limited data are available for restoration success with the feather-edge finish line when used with monolithic zirconia crowns with different occlusal reduction schemes.

PURPOSE

The purpose of this randomized clinical trial was to evaluate the clinical performance of 2 finish line designs (feather-edge and rounded shoulder) in relation to 2 occlusal designs (flat and planar) in endodontically treated teeth restored with monolithic zirconia crowns.

MATERIAL AND METHODS

Sixty-six complete-coverage monolithic zirconia crowns were provided for posterior endodontically treated teeth. The participants were divided into 3 groups based on the preparation design: the control group (PS) had a planar occlusal scheme with a rounded shoulder finish line; the first intervention group (FF) had a flat occlusal scheme with a feather-edge finish line; and the second intervention group (FS) had a flat occlusal scheme with a rounded shoulder finish line. The crowns were designed with the exocad software program and milled with a 5-axis machine. After cementation, clinical performance in terms of marginal adaptation, marginal discoloration, fracture, and secondary caries was evaluated by using the modified United States Public Health Service (USPHS) criteria. The gingival index score system was used to evaluate the gingival response. The scores were recorded immediately after cementation and at 3 subsequent follow-up visits every 3 months for 1 year. The chi-squared test was used in all comparisons of outcomes and follow-up durations (α=.05).

RESULTS

In terms of marginal adaptations, the control group (PS) demonstrated the best marginal adaptation scores during follow-up visits, followed by intervention 2 (FS), and lastly, intervention 1 (FF), which was scored mostly with Bravo. At the third follow-up visit, the intervention 1 (FF) group reported the most gingival responses of all groups. No significant difference among the groups was found in terms of marginal discoloration, fracture, or secondary caries at any of the follow-up visits. Each group received a perfect Alfa score of 100% on all 3 follow-up assessments.

CONCLUSIONS

In this 1-year randomized clinical trial, all evaluated preparation schemes and corresponding crowns were clinically successful. The clinical performance of monolithic zirconia crowns of the novel preparation design (FF) was successful in terms of marginal adaption, fracture, secondary caries, and marginal discoloration.

Fracture resistance and failure mode of endodontically treated premolars reconstructed by different preparation approaches: Cervical margin relocation and crown lengthening with complete and partial ferrule with three different post and core systems

PURPOSE

To assess the fracture resistance and failure mode of endodontically treated premolars reconstructed by different preparation approaches: cervical margin relocation (CMR) and crown lengthening (CL) with complete ferrule (CLF) and partial ferrule (CLPF) with three different post and core systems.

MATERIALS AND METHODS

In this in vitro study, 100 maxillary premolars were assigned to the following 10 groups according to their preparation approach and type of post and core system (n = 10): (I) control (intact teeth), (II) prefabricated fiber post (PFP) and composite core with CMR (PFP-CMR), (III) polyethylene fiber-reinforced composite (PEFRC) with CMR (PEFRC-CMR), (IV) casting post (CP) and core with CMR (CP-CMR), (V) PFP-CLPF, (VI) PEFRC-CLPF, (VII) CP-CLPF, (VIII) PFP-CLF, (IX) PEFRC-CLF, and (X) CP-CLF. After thermomechanical loading, the fracture resistance and failure mode were assessed. Data were analyzed statistically (α = 0.05).

RESULTS

In all post and core systems, the CLPF approach had lower fracture resistance than CMR (p < 0.05); CLF showed higher fracture resistance than CLPF only in the PFP system (p = 0.038). In PEFRC and CP systems, the difference between CLF and CLPF was not significant (p > 0.05). No significant difference was found in fracture resistance of different post and core systems with the same preparation approach (p > 0.05). CLPF showed the highest frequency of favorable, and CLF showed the highest frequency of unfavorable fractures.

CONCLUSION

CLPF yielded lower fracture resistance than CMR. The difference in fracture resistance was not significant between CLF and CMR but the frequency of unfavorable fractures was higher in CLF than in other groups.

The effect of two preparation designs on the fracture resistance and marginal adaptation of two types of ceramic crowns using CAD/CAM technology (In vitro study)

BACKGROUND

Recently, prosthodontic approaches involve more conservative procedures that include less invasive finish line preparations that use less ceramic thickness.

AIM OF THE STUDY

This in vitro study aimed to evaluate the effect of vertical preparation and modified vertical preparation designs on the marginal adaptation and fracture resistance of two types of ceramic crowns using CAD/CAM technology.

MATERIALS AND METHODS

Two typodont maxillary first premolars were embedded in acrylic resin. Forty positive replicas of epoxy resin dies were used that were divided into two groups depending on the preparation design (n = 20); Group V (Vertical): dies with feather edge finish line and Group MV (Modified vertical): dies with feather edge finish line, where a reverse shoulder of 1 mm depth was placed on the buccal surface 1.5 mm from the occlusal surface. Each group was further subdivided into two subgroups according to the type of ceramic material (n = 10): Subgroup Va and subgroup MVa for lithium disilicate (e.max CAD) and subgroup Vb and subgroup MVb for zirconia (zolid ht+). Crown restorations were made with CAD-CAM technology. The marginal adaptation was assessed using a stereomicroscope both prior to cementation and after cementation and aging. Fracture resistance was tested with a universal testing machine, and the data were statistically analyzed.

RESULTS

Marginal adaptation showed no significant differences between subgroups before or after cementation and aging. Three-way ANOVA indicated that preparation design (p = 0.516) and material (p = 0.269) had no significant effect, but cementation had a significant effect (p < 0.0001) on the marginal adaptation. According to two-way ANOVA test, Subgroup (MVb) showed the highest result followed by subgroup (Vb) and subgroub (MVa) and the least was subgroub (Va). Fracture modes showed no significant differences among the subgroups (p = 0.982).

CONCLUSIONS

Marginal adaptation of lithium disilicate and zirconia crowns remained clinically acceptable regardless of preparation design. While the modified vertical preparation with a reverse shoulder notably enhanced the fracture resistance of both materials, with zirconia demonstrating superior fracture resistance compared to lithium disilicate with average values exceeding premolar biting force.

Clinical application principles and new developments of zirconia crown

Zirconia crown has been widely used in the field of prosthodontics. Traditional zirconia exhibits excellent mechanical properties but lacks translucency. The introduction of transparent zirconia significantly enhances its aesthetic performance. In clinical applications, factors affecting the aesthetic results of full zirconia crown should be comprehensively considered, and the most suitable restoration should be chosen. Additionally, clinicians need to design appropriate tooth preparation dimensions and methods based on an individual patient's actual situation. During the clinical bonding process of zirconia, proper surface treatment of the tooth and restoration is essential. The selection of suitable adhesives is crucial for achieving optimal bonding strength and aesthetics.

Effect of deep margin elevation on fracture resistance of premolars restored with ceramic onlay: In vitro comparative study

Background

This in vitro comparative study aimed to compare the influence of two levels of deep margin elevation (2 and 3 mm) with either bulk-fill flowable composite or short fiber-reinforced flowable composite on the fracture resistance of maxillary first premolars restored with ceramic onlays.

Material and Methods

Fifty sound-extracted maxillary first premolar teeth were selected to prepare mesio-occluso-distal cavities with standardized dimensions. The cervical margins were extended 2 mm below the cemento-enamel junction on both mesial and distal sides. These teeth were randomly divided into five groups: Group I: no box elevation (control group). Group II: 2 mm marginal elevation with bulk-fill flowable composite. Group III: 2 mm marginal elevation with short fiber-reinforced flowable composite. Group IV: 3 mm marginal elevation with bulk-fill flowable composite. Group V: 3 mm marginal elevation with short fiber-reinforced flowable composite. After cementation, all teeth were subjected to a fracture resistance test using the universal testing machine, and the mode of failure was analyzed using a digital microscope at 20x magnification.

Results

The result showed a non-significant difference in the fracture resistance between 2 and 3 mm marginal elevation (p>0.05) with respect to each restorative material used for deep margin elevation. However, the fracture resistance of teeth elevated with short fiber-reinforced flowable composite was significantly higher than those elevated with bulk-fill flowable composite at both levels 2 and 3 mm, p=0.041 and 0.038 respectively.

Conclusions

The fracture resistance of premolars restored with a ceramic onlay was not influenced by the levels of deep margin elevation (2 or 3 mm). However, marginal elevation with short fiber-reinforced flowable composites provided higher fracture resistance than those elevated with bulk-fill flowable composites, and those without marginal elevation. Key words:Fracture Resistance, Short fiber reinforced flowable composite, Bulk-fill flowable composite, Ceramic onlay, Cervical margin elevation.

The 3-year cumulative survival rates of posterior monolithic zirconia crowns and their antagonist teeth, and their influencing factors

PURPOSE

The purpose of this study was to evaluate the 3-year cumulative survival rates of posterior single monolithic zirconia crowns (MZCs) and their antagonists, and to analyze the influencing factors.

METHODS

The clinical outcomes of posterior single MZCs and their abutment teeth with antagonists, and the antagonists between April 2014 and September 2020 were evaluated retrospectively. The 3-year cumulative survival rates were calculated and associations between the survival time and predictor variables ("Jaw", "Tooth", and "Pulpal condition") were also verified using Cox proportional hazards models and hazard ratios (HRs).

RESULTS

The 3-year cumulative survival rate of single MZCs was 89.8% (9 of 177 MZCs, 95% confidence interval (CI): 80.0-95.1%). Cox proportional hazards models showed non-vital teeth were significantly associated with failure (HR: 2.76e + 9, P = 0.012). The 3-year cumulative survival rate of antagonists was 94.8% (7 of 171 antagonists, 95% CI: 89.3-97.6%). Non-vital antagonists were also identified as an independent predictor for failure in Cox proportional hazards models (HR: 7.83, P = 0.03).

CONCLUSION

Although posterior single MZCs were clinically acceptable, non-vital pulpal condition could be a potential risk factor for failures in the abutment and antagonist teeth of MZCs.

Fracture Strength of Monolithic Zirconia Crowns with Modified Vertical Preparation: A Comparative In Vitro Study

Objective  The aim of this study was to evaluate the influence of different marginal designs (deep chamfer, vertical, and modified vertical with reverse shoulder) on the fracture strength and failure modes of monolithic zirconia crowns.

Materials and Methods  Thirty sound human maxillary first premolar teeth with comparable size were used in this study. The teeth were divided randomly into three groups according to the preparation design ( n = 10): (1) group A: teeth prepared with a deep chamfer finish line; (2) group B: teeth prepared with vertical preparation; and (3) group C: teeth prepared with modified vertical preparation, where a reverse shoulder of 1 mm was placed on the buccal surface at the junction of middle and occlusal thirds. All samples were scanned by using an intraoral scanner (CEREC Omnicam, Sirona, Germany), and then the crowns were designed by using Sirona InLab 20.0 software and milled with a 5-axis machine. Each crown was then cemented on its respective tooth with self-adhesive resin cement by using a custom-made cementation device. A single load to failure test was used to assess the fracture load of each crown by using a computerized universal testing machine that automatically recorded the fracture load of each sample in Newton (N).

Statistical Analysis  The data were analyzed statistically by using one-way analysis of variance test and Bonferroni test at a level of significance of 0.05.

Results  The highest mean of fracture load was recorded by chamfer (2,969.8 N), which followed by modified vertical (2,899.3 N) and the lowest mean of fracture load was recorded by vertical (2,717.9 N). One-way ANOVA test revealed a significant difference among the three groups. Bonferroni test showed a significant difference between group A and group B, while a nonsignificant difference was revealed between group C with group A and group B.

Conclusion  Within the limitations of this in vitro study, the mean values of fracture strength of monolithic zirconia crowns of all groups were higher than the maximum occlusal forces in the premolar region. The modification of the vertical preparation with a reverse shoulder placed at the buccal surface improved the fracture strength up to the point that it was statistically nonsignificant with the chamfer group.

Performance of stereolithography and milling in fabricating monolithic zirconia crowns with different finish line designs

Subtractive manufacturing has become the dominant method in fabricating zirconia dental restorations while additive manufacturing is emerging as a potential alternative. The aim of this in vitro study was to investigate the performance of stereolithography (SLA) and milling in fabricating monolithic zirconia crowns with different finish line designs. Full-contour crowns with three finish lines (chamfer, rounded shoulder, knife-edge) were designed and fabricated by SLA and milling. Fabrication accuracy was accessed by 3D deviation analysis and margin quality was characterized under microscopes. The obtained root mean square value was significantly influenced by finish line design (P < 0.05) but not by fabrication method (P＞0.05). However, the color-difference map showed crowns fabricated by SLA and milling had different error distribution in external surfaces. SLA-printed crowns exhibited margins of rounded line angle and without small flaws, although large chippings were found in knife-edged crowns. In milling group, crowns showed margins of sharp line angle and with separate chippings. More and larger margin chippings were found in knife-edged crowns by milling. The results indicate that SLA and milling can fabricate monolithic zirconia crowns of comparable accuracy and knife-edged crowns are prone to large margin chippings by either of the two manufacturing methods.

Effect of Reduced Occlusal Thickness with Two Margin Designs on Fracture Resistance of Monolithic Zirconia Crowns

Objectives  The aim of this study was to compare the effects of two margin designs (shoulderless and slight chamfer) with two occlusal thicknesses on fracture resistance and failure mode of the monolithic zirconia crowns.

Materials and Methods  Forty nickel–chromium dies were duplicated from the previous two prepared teeth using a three-dimensional optical scanner. Nickel–chromium supporting dies were divided into two main groups ( n = 20) according to the type of margin design: group A, slight chamfer margin design and group B, shoulderless margin design. These groups were further divided into two subgroups according to the occlusal thicknesses (0.5 and 1 mm). The digital imaging of each die was done using a three-dimensional optical scanner, then zirconia blocks were milled by 5-axis machine. The crowns were cleaned by alcohol, air dried, and cemented by resin cement. Next, the crowns were subjected to 500 hot and cold cycles (30 seconds for each cycle). The samples were subjected to a static load until failure using an electronic universal testing machine and fracture resistance was recorded in Newton (N).

Statistical Analysis  Data were analyzed using the test of normality (Shapiro–Wilk test) and two-way analysis of variance (ANOVA) test.

Results   The highest mean fracture load was recorded by the shoulderless (1 mm occlusal thickness) subgroup (3,992.5 N), followed by shoulderless (0.5 mm occlusal thickness) subgroup (3,244.4 N), and the slight chamfer (1 mm occlusal thickness) subgroup (2,811 N). The lowest mean of fracture load was recorded by slight chamfer (0.5 mm occlusal thickness) subgroup (1,632.9 N). The two-way ANOVA test revealed a significant difference between the four subgroups. Regarding the fracture mode, the slight chamfer subgroups showed a severe fracture of the restoration while the shoulderless subgroups showed a fracture through the midline of the restoration.

Conclusion  Within the limitation of the comparative study, shoulderless margin design has a more favorable outcome than a slight chamfer design in all thicknesses. Although the restoration with reduced occlusal thickness has lower fracture resistance than 1 mm occlusal thickness, the 0.5 mm restorations still can tolerate occlusal forces.