Mechanical interactions of cuspal-coverage designs and cement thickness in a cusp-replacing ceramic premolar restoration: a finite element study

Fracture strength of endocrowns after thermomechanical aging

This in-vitro study aimed to evaluate the fracture strength (FS; N) of composite, feldspathic, and glass-ceramic computer-aided design/computer-aided manufacturing (CAD/CAM) endocrowns after thermomechanical aging. Seventy non-carious human molars were randomly divided into seven groups, according to the CAD/CAM material used for endocrown fabrication. Intact molars without cavity preparations were used as control (n = 10). Following endodontic treatment, standardized endocrown cavities were prepared and endocrowns were fabricated using composite (Cerasmart270, CS and Grandio Blocs, GB), fired and milled zirconia-reinforced lithium silicate (Celtra Duo, CD), leucite-reinforced feldspar ceramic (LRF Initial, LRF), and feldspathic (Cerec Blocks, CE) materials which were luted with universal adhesive (Futurabond U; Voco) and dual-cure resin cement (Bifix QM). Following thermocycling for 20,000 cycles and 480,000 load cycles in a chewing simulator (CS-4.2, SD Mechatronik), FS was evaluated (Instron). Data were analyzed with one-way ANOVA and post hoc Tukey's tests (p < 0.05). FS was significantly influenced by the tested material (p = 0.00). CS had the highest FS, which was not significantly different from intact molars and fired CD (p > 0.05). There were no significant differences in FS between LRF, GB, and CD, which were significantly higher than CE. Most of the failure modes of CS, CD, and GB were repairable, whereas those of CE were irreparable. All the tested materials withstood clinically relevant axial forces. Composite endocrowns exhibited more favorable fracture pattern, whereas feldspathic and leucite-reinforced feldspar ceramic endocrowns exhibited mostly irreparable fractures.

Do onlays and crowns offer similar outcomes to posterior teeth with mesial-occlusal-distal preparations? A systematic review

OBJECTIVE

Teeth prepared for mesial-occlusal-distal (MOD) restorations have a significant risk of cusp fracture. Crowns and onlays can provide cusp coverage to reinforce posterior teeth at risk. Onlays are often more conservative of tooth structure which may be an advantage for teeth with large MOD preparations. It remains uncertain how onlays and crowns compare for posterior teeth with MOD tooth structure loss. The purpose of this systematic review was to compare the resistance to fracture, success rate, survival rate, and failure rate of teeth with MOD preparations restored with onlays or crowns.

MATERIALS AND METHODS

An electronic search queried Medline (PubMed), Embase (Ovid), Scopus, the Cochrane Library, and grey literature (OpenGrey) from database inception through April 29, 2023.

RESULTS

After eliminating duplicates and irrelevant records, 32 manuscripts were assessed. Only three publications met the criteria for inclusion. Most exclusions were due to poor reporting of restorative design and the amount of tooth structure remaining, or due to combining various restorative designs. Due to the limited sample size and high heterogeneity, no meta-analysis was conducted. One study observed a better outcome for onlays and two observed no difference. All three studies reported the mode of failure for crowns as more catastrophic whereas teeth with onlays could be salvaged.

CONCLUSIONS

Onlays may be an advantageous alternative to crowns for teeth with MOD preparations, but the level of evidence is insufficient to draw meaningful conclusions.

CLINICAL SIGNIFICANCE

Current evidence is insufficient to determine whether onlays or crowns are providing a different outcome when used to restore posterior teeth with MOD tooth structure loss. However, the fracture of teeth with MOD tooth structure loss restored with onlays appears to be less catastrophic than when restored with crowns.

Volumetric and dimensional accuracy assessment of CAD-CAM-manufactured dental prostheses from different materials

STATEMENT OF PROBLEM

In computer-aided design and computer-aided manufacturing (CAD-CAM) dentistry, the CAD of the prosthesis represents the clinical prerequisite design to restore the treated tooth. However, how closely the CAM prosthesis shape matches the CAD, particularly in relation to different materials, is unclear.

PURPOSE

The purpose of this in vitro study was to evaluate onlays designed and manufactured with the same CAD-CAM system but manufactured with different materials.

MATERIAL AND METHODS

A single standard tessellation language (STL) model was used to produce 6 composite resin onlays, 6 leucite glass-ceramic onlays, and 6 lithium disilicate glass-ceramic onlays. The onlays were digitized by using an X-ray microtomographic protocol with a metrological calibration. The CAD model was then compared with the scans of the different onlays. An analysis by region of interest was then carried out to assess the accuracy and reliability of the dimensional accuracy.

RESULTS

The composite resin and the lithium disilicate glass-ceramic had the best dimensional accuracy. The leucite glass-ceramic exhibited a lack of trueness linked to consistent overmilling. The composite resin had less peripheral chipping than the glass-ceramics.

CONCLUSIONS

The composite resin and the lithium disilicate glass-ceramic material exhibited satisfactory dimensional accuracy. Milling the glass-ceramic before crystallization considerably improved dimensional accuracy.

Fracture resistance of resin endocrowns with and without fiber reinforced composite base material: A preliminary study

OBJECTIVE

The aim of this study was to investigate the effects of fiber-reinforced composite base material on fracture resistance and fracture pattern of endodontically treated maxillary premolars restored with endocrowns using two different resin nanoceramic computer-aided design and computer-aided manufacturing (CAD/CAM) restorative material.

METHODS

Forty extracted sound maxillary premolars with an occlusal reduction of 2 mm above the cementoenamel junction (CEJ) was performed following root canal treatment. Mesial interproximal box was prepared for each tooth at the margin of the CEJ and randomly distributed into four groups (n = 10) as follows: Group A, no resin build-up in the pulp chamber; Group B, 2 mm of fiber-reinforced composite (FRC) build-up (EverX Posterior, GC).; Group C, no resin build-up in pulp chamber; Group D, 2 mm of FRC build-up. Groups A and B were prepared with resin nanoceramic (RNC) consisting ceramic nanofillers (Lava Ultimate 3 M ESPE), while Group C and D were prepared with RNC consisting ceramic nanohybrid fillers (Cerasmart GC Corp). All samples were subjected to 1,200,000 chewing cycles (1.6 Hz, 50 N) and 5000 thermal cycles (5°C-55°C) for artificial aging on a chewing simulator with thermal cycles (CSTC). Samples that survived the CSTC test without being damaged were subjected to a load-to-fracture test.

RESULTS

The highest mean fracture strength was found in Group D (936.0 ± 354.7) and lowest in Group A (684.2 ± 466.9). Fracture strength was higher in groups where FRC was used as a base material than plain restorations. However, there were no significant differences between the Lava and Cerasmart groups with and without FRC (p > 0.05). Most of the samples were irreparably fractured under CEJ.

CONCLUSION

Using short FRCs as a resin base material did not significantly improve fracture resistance. Cerasmart and Lava blocks had similar fracture resistance and fracture pattern.

Effect of surface treatment, ferrule height, and luting agent type on pull-out bond strength of monolithic zirconia endocrowns

PURPOSE

To evaluate the effect of different surface treatments, ferrule heights, and luting agents on the pull-out bond strength (PBS) of computer-aided design/computer-aided manufacturing (CAD-CAM) monolithic endocrowns.

METHODS

After endodontic treatment and preparation for two endocrown designs (ferrule height 0 mm or 2 mm), CAD-CAM monolithic zirconia endocrowns were fabricated for 80 mandibular molars. Each endocrown design group was then divided on the basis of surface treatment into two groups: half were air-abraded and half were air-abraded/laser-irradiated. Then, all treated groups were further divided into two subgroups (n = 10) and cemented to teeth with either a 10-methacryloyloxydecyl dihydrogen phosphate (MDP)-containing resin luting agent (Panavia SA) or a combination of MDP-containing primer and MDP-free resin luting agent (Monobond Plus/Multilink Automix). PBS was measured with a universal test machine after simulated chewing and thermocycling. Three-way ANOVA and the post-hoc Bonferroni test were used for statistical analysis.

RESULTS

PBS was significantly associated with type of surface treatment, type of luting agent, and ferrule height. Air-abraded/laser-irradiated endocrowns with a 2-mm ferrule that were cemented with Monobond Plus/Multilink Automix had the highest PBS (P < 0.05).

CONCLUSION

Surface treatment with air abrasion/laser irradiation, presence of a ferrule, and priming with an MDP-containing primer increased the PBS of monolithic zirconia endocrowns.

Finite element and in vitro study on biomechanical behavior of endodontically treated premolars restored with direct or indirect composite restorations

Objectives of the study were to investigate biomechanical properties of severely compromised premolars restored with composite restorations using finite element analysis (FEA), and in vitro fracture resistance test. A 3-D model of an endodontically treated premolar was created in Solidworks. Different composite restorations were modelled (direct restoration-DR; endo-crown-EC; post, core, and crown-C) with two different supporting tissues: periodontal ligament/alveolar bone (B), and polymethyl methacrylate (PMMA). Models were two-point axially loaded occlusally (850 N). Von Mises stresses and strains were calculated. The same groups were further tested for static fracture resistance in vitro (n = 5, 6.0 mm-diameter ball indenter, vertical load). Fracture resistance data were statistically analyzed (p < 0.050). The highest stresses and strains in all FEA models were observed on occlusal and vestibular cervical surfaces, corresponding to fracture propagation demonstrated in vitro. C showed the lowest stress in dentin, while EC showed lower stresses and strains in crown cement. B models demonstrated larger high stress areas in the root than PMMA models. No significant differences in fracture resistance (N) were observed between groups (DR: 747.7 ± 164.0, EC: 867.3 ± 108.1, C: 866.9 ± 126.3; p = 0.307). More conservative restorations seem a feasible alternative for endodontically treated premolars to conventional post-core-crown.

Effects of Cuspal Inclination and Luting Agent on Fracture Load Values in Composite Resin CAD/CAM Crowns

The purpose of this study was to evaluate whether change in cuspal inclination influences the fracture load values of composite resin computer-aided design/computer-aided manufacturing (CAD/CAM) crowns. Abutment teeth and CAD/CAM crowns were prepared as they would be for treating a mandibular first premolar with two cusps. The CAD/CAM crowns were designed so that 1) the principal stress lines would be radially distributed from the two points of contact with the indenter to the occlusal area of the abutment (Type I), or 2) the principal stress lines would pass outside the occlusal area of the abutment (Types II and III). The CAD/CAM crowns were mounted on the abutments using one of two types of resin or polycarboxylate cement. Fracture load values were measured using a universal tester. The Type I CAD/CAM crowns exhibited the highest mean fracture load value, followed by the Type II crowns and then the Type III crowns, with significant differences seen between all types (p<0.05). The luting agent used (resin or polycarboxylate cement) showed no effect on the fracture load value. With the Type II and Type III crowns, significant differences in the fracture load value were observed between the Super-Bond and Hy-Bond polycarboxylate cement groups (p<0.05).

Influence of fiber insertion and different material type on stress distribution in endocrown restorations: a 3D-FEA study

The study aimed to evaluate the effects of fibers insertion and restorative material type on the stress distribution in endocrowns with finite element analysis. Five 3D models of first mandibular molars were created and restored as follows: (1) IN: intact tooth, (2) IPS-E: tooth restored with lithium disilicat ceramic endocrowns, (3) C-E: tooth restored with composite endocrowns, (4) IPS-E + F: lithium disilicate ceramic endocrowns + fiber, (5) C-E + F: composite endocrowns + fiber. Vertical masticatory load was imitated with finite element analysis. The equivalent stress of von Mises failure criterion (mvM) was calculated. The maximum mvM stress, enamel/crown, dentin and cement were compared among models and strength of the materials. Endocrowns presented a lower mvM stress level than intact tooth. In IPS-E, the mvM stress values in the crown and dentin were higher than C-E, while the mvM stress values in cement were higher in C-E group. Fibers insertion did not affect the stress level of IPS-E and C-E groups. In IPS model, fiber showed more stress absorption than C-E. The restorative material type changed the stress distribution of endocrown restorations. The fiber application did not affect the stress distribution in either endocrown group. But, more stress absorption was observed in fiber under IPS-E than C-E.

Validated Finite Element Models of Premolars: A Scoping Review

Finite element (FE) models are widely used to investigate the biomechanics of reconstructed premolars. However, parameter identification is a complex step because experimental validation cannot always be conducted. The aim of this study was to collect the experimentally validated FE models of premolars, extract their parameters, and discuss trends. A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Records were identified in three electronic databases (MEDLINE [PubMed], Scopus, The Cochrane Library) by two independent reviewers. Twenty-seven parameters dealing with failure criteria, model construction, material laws, boundary conditions, and model validation were extracted from the included articles. From 1306 records, 214 were selected for eligibility and entirely read. Among them, 19 studies were included. A heterogeneity was observed for several parameters associated with failure criteria and model construction. Elasticity, linearity, and isotropy were more often chosen for dental and periodontal tissues with a Young's modulus mostly set at 18-18.6 GPa for dentine. Loading was mainly simulated by an axial force, and FE models were mostly validated by in vitro tests evaluating tooth strains, but different conditions about experiment type, sample size, and tooth status (intact or restored) were reported. In conclusion, material laws identified herein could be applied to future premolar FE models. However, further investigations such as sensitivity analysis are required for several parameters to clarify their indication.

Effect of Differences in Axial Thickness and Type of Cement on Fracture Resistance in Composite Resin CAD/CAM Crowns

The purpose of this study was to investigate the influence of differences in axial thickness and type of cement on fracture load in CAD/CAM crowns. Assuming the mandibular first premolar to be the abutment tooth, 4 types of crown with different axial thicknesses and radii of curvature were prepared. To unify external design, the morphology of the crown margins was set at 0.15, 0.30, 0.45, or 0.60 mm, thus maintaining uniform axial form of the crowns. The CAD/CAM crowns and abutment teeth were bonded using each of 2 types of resin cement or polycarboxylate cement. The fracture load value was measured using a universal testing machine and the destruction phase observed.No significant difference was observed with change in axial thickness. The fracture load values with each of the 2 types of resin cement used were significantly higher than that with polycarboxylate cement (p<0.01). These results suggest that the fracture load values of CAD/CAM crowns are not influenced by differences in the axial thickness of the crown, and that they are higher when bonding is achieved with resin rather than polycarboxylate cement.

Effect of Endocrown Restorations with Different CAD/CAM Materials: 3D Finite Element and Weibull Analyses

The aim of this study was to evaluate the effects of two endocrown designs and computer aided design/manufacturing (CAD/CAM) materials on stress distribution and failure probability of restorations applied to severely damaged endodontically treated maxillary first premolar tooth (MFP). Two types of designs without and with 3 mm intraradicular extensions, endocrown (E) and modified endocrown (ME), were modeled on a 3D Finite element (FE) model of the MFP. Vitablocks Mark II (VMII), Vita Enamic (VE), and Lava Ultimate (LU) CAD/CAM materials were used for each type of design. von Mises and maximum principle values were evaluated and the Weibull function was incorporated with FE analysis to calculate the long term failure probability. Regarding the stresses that occurred in enamel, for each group of material, ME restoration design transmitted less stress than endocrown. During normal occlusal function, the overall failure probability was minimum for ME with VMII. ME restoration design with VE was the best restorative option for premolar teeth with extensive loss of coronal structure under high occlusal loads. Therefore, ME design could be a favorable treatment option for MFPs with missing palatal cusp. Among the CAD/CAM materials tested, VMII and VE were found to be more tooth-friendly than LU.

Influence of diameter and intraradicular post in the stress distribution. Finite element analysis

Abstract Introduction The biomechanical behavior of endodontically treated teeth depending on the selected restorative material and tooth situation to be restored. Objective To analyze by the two-dimensional finite element method the biomechanical behavior of different diameters in intraradicular posts and teeth with coronal remaining of 2mm. Material and method Six models were made with three types of posts, as follows: Glass fiber post, carbon fiber post, and cast metal post, both with diameter # 1 (1.1 mm in diameter) and # 2 (1.3 mm of diameter). The modeling was performed using the Rhinoceros 4.0 program. The FEMAP 10.2 and NEiNastran 9.2 programs were used to develop finite element models. The loading used was 100N for axial and oblique forces. The results were visualized using the von Mises stress map. The statistical analysis was made using analysis of variance (ANOVA) and Tukey post-test, with a significance level of 5%. Result The oblique loading stress values were higher than the axial loading (p<0.001) for both situations. The glass fiber post showed the lowest concentrations of stress on both loads (p<0.001). The carbon fiber post presented significant difference compared to the cast metal post, only in the oblique load (p=0.007). The diameter did not increase the stress of the evaluated posts (p=0.302). Conclusion The fiber posts were more favorable for restoration of endodontically treated teeth; the increase of diameter did not influence the increase of tension; the oblique load was more harmful for both posts and tooth structure.

Modeling and validation of a 3D premolar for finite element analysis

Abstract Introduction The development and validation of mathematical models is an important step of the methodology of finite element studies. Objective This study aims to describe the development and validation of a three-dimensional numerical model of a maxillary premolar for finite element analysis. Material and method The 3D model was based on standardized photographs of sequential slices of an intact premolar and generated with the use of SolidWorks Software (Dassault, France). In order to validate the model, compression and numerical tests were performed. The load versus displacement graphs of both tests were visually compared, the percentage of error calculated and homogeneity of regression coefficients tested. Result An accurate 3D model was developed and validated since the graphs were visually similar, the percentage error was within acceptable limits, and the straight lines were considered parallel. Conclusion The modeling procedures and validation described allows the development of accurate 3D dental models with biomechanical behavior similar to natural teeth. The methods may be applied in development and validation of new models and computer-aided simulations using FEM.

Examination of ceramic restoration adhesive coverage in cusp-replacement premolar using acoustic emission under fatigue testing

Background

This study investigates CAD/CAM ceramic cusp-replacing restoration resistance with and without buccal cusp replacement under static and dynamic cyclic loads, monitored using the acoustic emission (AE) technique.

Method

The cavity was designed in a typical MODP (mesial-occlusal-distal-palatal) restoration failure shape when the palatal cusp has been lost. Two ceramic restorations [without coverage (WOC) and with (WC) buccal cuspal coverage with 2.0 mm reduction in cuspal height] were prepared to perform the fracture and fatigue tests with normal (200 N) and high (600 N) occlusal forces. The load versus AE signals in the fracture and fatigue tests were recorded to evaluate the restored tooth failure resistance.

Results

The results showed that non-significant differences in load value in the fracture test and the accumulated number of AE signals under normal occlusal force (200 N) in the fatigue test were found between with and without buccal cuspal coverage restorations. The first AE activity occurring for the WOC restoration was lower than that for the WC restoration in the fracture test. The number of AE signals increased with the cyclic load number. The accumulated number of AE signals for the WOC restoration was 187, higher than that (85) for the WC restoration under 600 N in the fatigue test.

Conclusion

The AE technique and fatigue tests employed in this study were used as an assessment tool to evaluate the resistances in large CAD/CAM ceramic restorations. Non-significant differences in the tested fracture loads and accumulated number of AE signals under normal occlusal force (200 N) between different restorations indicated that aggressive treatment (with coverage preparation) in palatal cusp-replacing ceramic premolars require more attention for preserving and protecting the remaining tooth.

Unravelling the functional biomechanics of dental features and tooth wear

Most of the morphological features recognized in hominin teeth, particularly the topography of the occlusal surface, are generally interpreted as an evolutionary functional adaptation for mechanical food processing. In this respect, we can also expect that the general architecture of a tooth reflects a response to withstand the high stresses produced during masticatory loadings. Here we use an engineering approach, finite element analysis (FEA), with an advanced loading concept derived from individual occlusal wear information to evaluate whether some dental traits usually found in hominin and extant great ape molars, such as the trigonid crest, the entoconid-hypoconulid crest and the protostylid have important biomechanical implications. For this purpose, FEA was applied to 3D digital models of three Gorillagorilla lower second molars (M₂) differing in wear stages. Our results show that in unworn and slightly worn M₂s tensile stresses concentrate in the grooves of the occlusal surface. In such condition, the trigonid and the entoconid-hypoconulid crests act to reinforce the crown locally against stresses produced along the mesiodistal groove. Similarly, the protostylid is shaped like a buttress to suffer the high tensile stresses concentrated in the deep buccal groove. These dental traits are less functional in the worn M₂, because tensile stresses decrease physiologically in the crown with progressing wear due to the enlargement of antagonistic contact areas and changes in loading direction from oblique to nearly parallel direction to the dental axis. This suggests that the wear process might have a crucial influence in the evolution and structural adaptation of molars enabling to endure bite stresses and reduce tooth failure throughout the lifetime of an individual.

Effect of the crown design and interface lute parameters on the stress-state of a machined crown-tooth system: a finite element analysis

The effect of preparation design and the physical properties of the interface lute on the restored machined ceramic crown-tooth complex are poorly understood. The aim of this work was to determine, by means of three-dimensional finite element analysis (3D FEA) the effect of the tooth preparation design and the elastic modulus of the cement on the stress state of the cemented machined ceramic crown-tooth complex. The three-dimensional structure of human premolar teeth, restored with adhesively cemented machined ceramic crowns, was digitized with a micro-CT scanner. An accurate, high resolution, digital replica model of a restored tooth was created. Two preparation designs, with different occlusal morphologies, were modeled with cements of 3 different elastic moduli. Interactive medical image processing software (mimics and professional CAD modeling software) was used to create sophisticated digital models that included the supporting structures; periodontal ligament and alveolar bone. The generated models were imported into an FEA software program (hypermesh version 10.0, Altair Engineering Inc.) with all degrees of freedom constrained at the outer surface of the supporting cortical bone of the crown-tooth complex. Five different elastic moduli values were given to the adhesive cement interface 1.8GPa, 4GPa, 8GPa, 18.3GPa and 40GPa; the four lower values are representative of currently used cementing lutes and 40GPa is set as an extreme high value. The stress distribution under simulated applied loads was determined. The preparation design demonstrated an effect on the stress state of the restored tooth system. The cement elastic modulus affected the stress state in the cement and dentin structures but not in the crown, the pulp, the periodontal ligament or the cancellous and cortical bone. The results of this study suggest that both the choice of the preparation design and the cement elastic modulus can affect the stress state within the restored crown-tooth complex.

The evolutionary paradox of tooth wear: simply destruction or inevitable adaptation?

Over the last century, humans from industrialized societies have witnessed a radical increase in some dental diseases. A severe problem concerns the loss of dental materials (enamel and dentine) at the buccal cervical region of the tooth. This “modern-day” pathology, called non-carious cervical lesions (NCCLs), is ubiquitous and worldwide spread, but is very sporadic in modern humans from pre-industrialized societies. Scholars believe that several factors are involved, but the real dynamics behind this pathology are far from being understood. Here we use an engineering approach, finite element analysis (FEA), to suggest that the lack of dental wear, characteristic of industrialized societies, might be a major factor leading to NCCLs. Occlusal loads were applied to high resolution finite element models of lower second premolars (P₂) to demonstrate that slightly worn P₂s envisage high tensile stresses in the buccal cervical region, but when worn down artificially in the laboratory the pattern of stress distribution changes and the tensile stresses decrease, matching the results obtained in naturally worn P₂s. In the modern industrialized world, individuals at advanced ages show very moderate dental wear when compared to past societies, and teeth are exposed to high tensile stresses at the buccal cervical region for decades longer. This is the most likely mechanism explaining enamel loss in the cervical region, and may favor the activity of other disruptive processes such as biocorrosion. Because of the lack of dental abrasion, our masticatory apparatus faces new challenges that can only be understood in an evolutionary perspective.

Estimation of the retainer height biomechanical contribution in posterior resin-bonded fixed partial dentures: a structural-thermal coupled finite element analysis

This study determines the RBFPD (resin-bonded fixed partial dentures) biomechanical aspects to retainer height using structural-thermal coupled finite element (FE) analysis under normal (37°C) and high (51°C) oral temperatures. Three RBFPD FE models with different retainer heights (100, 75, and 50% of the distance from 2 mm above the CE (cementum-enamel) junction to the occlusal surface) were created using image processing, contour stacking, and mapping mesh procedures. After FE model validation, the maximum first principal and von Mises stresses in the remaining tooth (σ(T)) and prosthesis (σ(P)), were recorded for all models under structural-thermal coupled analyses. The simulation results showed that the σ(T) and σ(p) values decreased with greater retainer height as a result of the increasing prosthesis stiffness and maximizing bonding area between the enamel and retainer at normal oral temperature (37°C). However, no significant stress differences were found according to the retainer height varying dimensions at high (51°C) temperatures. The RBFPD retainer height biomechanical response is dominated by the structural analysis result (at 37°C) and it is recommended that the prosthesis retainer have as great a height as possible to decrease the stress values.