Fracture resistance of CAD-CAM monolithic ceramic and veneered zirconia molar crowns after aging in a mastication simulator

Should the load-to-fracture test for CAD/CAM monolithic molar crowns be standardized and how? A systematic review and finite element analysis

The load-to-fracture test is widely used to evaluate crowns made of new CAD/CAM materials, even though its validity in predicting clinical performances is often questioned. Despite its limitations, the test is useful in assessing the load-bearing capacity of crowns subjected to accidental overloads and setting up step-stress regimes for fatigue testing. This study combined a systematic review (SR) and finite element analysis (FEA) to assess whether the test should be standardized and how. The SR evaluated load-to-fracture studies of monolithic CAD/CAM molar crowns published in Q1 and Q2 journals. Findings from 85 studies highlighted the lack of standardization in test methods, particularly regarding loading head type and die material. This variability led to a wide dispersion of fracture load results, limiting the utility of the load-to-fracture test. The FEA evaluated the influence of loading head type and die material on tensile stress distribution in lithium disilicate (LD) and polymer-infiltrated ceramic network (PICN) crowns. Eight in vitro conditions were simulated, varying the loading head (4 mm and 10 mm spheres, inverse V-shaped device, opposing teeth) and die material (stiff, E = 207 GPa; non-stiff, E = 13 GPa). The FEA confirmed that the stress distribution and peak tensile stress in LD and PICN crowns depend significantly on these factors as well as the crown material properties, with the peak stress variation from LD to PICN ranging from -4 % to 237 %. Using larger-diameter spheres with a die material approximating dentin in stiffness resulted in stress distributions more representative of clinical conditions.

Tooth Preparation Assessment Criteria for All-Ceramic CAD/CAM Posterior Crowns: An Evidence Map

BACKGROUND

An evidence map review was used to determine universal criteria for all-ceramic CAD/CAM posterior crowns to ensure standardized assessments by dental faculty, students, and practitioners.

MATERIALS AND METHODS

Covidence was used to perform the evidence map review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Web of Science (WOS), Embase, Dentistry and Oral Sciences Source (EBSCO), and MEDLINE (Ovid) were searched over a 10-year range (January 2012-December 2023), English only. This was complimented by a manual search. Descriptive statistics (i.e. frequencies and modes) and a chi-square goodness of fit test were used.

RESULTS

A total of 640 articles were identified, out of which 73 were selected for review across six reduction parameters: occlusal reduction, axial reduction, finish line reduction, total occlusal convergence (TOC), preparation surface finish, and anatomic form. Zirconia was excluded from this analysis. Significant differences were found between the observed and expected frequencies of consolidated parameters associated with occlusal reduction and finish line shoulder parameters at the p ≤ 0.05 level. There were no significant differences found between the observed and expected frequencies of the consolidated reduction parameters associated with finish line chamfer, axial reduction, surface finish, or TOC (p > 0.05).

CONCLUSIONS

Recommendation parameters for all-ceramic CAD/CAM posterior crown preparations are 1.5-2.0 mm for the occlusal reduction and 1.0 mm for the reduction of the shoulder finish line. Recommendations of at least 1.0 mm for the chamfer reduction, 12° for the TOC, 1.0-1.5 mm for the axial reduction, and a smooth preparation surface finish with internally rounded angles were also made, though none of these results were statistically significant. The literature review revealed the "finish line" category is multi-dimensional suggesting a more encompassing term as "finish boundary profile (FBP)."

Mechanical and biocompatibility testing of zirconia and lithium disilicate ceramics: An in vitro study

STATEMENT OF PROBLEM

High-translucency zirconia and lithium disilicate are among the most used materials in contemporary fixed prosthodontics because of their excellent esthetic and mechanical properties. However, their different cementation techniques, physical properties, and biocompatibility profiles can influence the clinician's choice.

PURPOSE

The purpose of this in vitro study was to evaluate the mechanical strength and adhesive cementation techniques for zirconia and lithium disilicate materials through mechanical testing, including compressive and pull-out tests. The biocompatibility of these materials was also assessed.

MATERIAL AND METHODS

A total of 72 human maxillary molars that were free from damage were embedded in acrylic resin and prepared 1 mm occlusal to the enamel-cementum junction. The specimens were divided into 3 groups: lithium disilicate (CAD), zirconia High-Translucency HT (CAD), and lithium disilicate (PRESS). Following the recommended cementation protocols, compression and pull-out tests were performed. Twelve disks of each group were fabricated to test the integration of gingival fibroblasts. Human gingival fibroblasts were isolated from gingival biopsies and cultured in Dulbecco modified Eagle medium (DMEM). Cell viability was determined using the 3-(4,5-di-methylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, serving as an indicator of cellular respiration.

RESULTS

Zirconia was the most mechanically efficient material, with a high resistance value (2081.4 ±405.4 N). The pull-out test determined that CAD-CAM lithium disilicate had similar adhesive cementation strength (244.3 ±29.3 N) to the other groups. In terms of biocompatibility, all materials demonstrated good results, with lithium disilicate CAD emerging as the most biocompatible material. Statistically significant differences were observed between the zirconia HT material and lithium disilicate PRESS (P=.006) and between lithium disilicate CAD and lithium disilicate PRESS (P=.002).

CONCLUSIONS

All the monolithic restorations analyzed have shown excellent results in terms of mechanical properties, adhesion, and biocompatibility. Zirconia exhibited outstanding mechanical properties, making it an ideal choice for applications requiring high strength. To achieve adhesion results comparable with those of lithium disilicate, a protocol using airborne-particle abrasion and silane with 10-MDP is recommended. This approach ensures optimal adhesion, enhancing the longevity and effectiveness of the restoration.

Thermomechanical aging effects on vertical marginal gap and fracture resistance: a comparative study of Bioflx and traditional pediatric crowns

BACKGROUND

Various types of crowns are used for full-coverage restoration of primary teeth affected by caries, developmental defects, or after pulp therapy. Prefabricated Stainless Steel and Zirconia crowns are commonly utilized. Bioflx crowns, which blend the properties of Stainless Steel and Zirconia, provide a flexible and aesthetically pleasing alternative.

AIM

This study aimed to evaluate the vertical marginal gap and fracture resistance of Bioflx pediatric crowns compared to Zirconia and Stainless Steel crowns following thermomechanical aging.

METHODS

This in-vitro study was conducted using mandibular second primary crowns of three different materials (n = 30). Crowns were divided into three groups; Zirconia crowns group (n = 10, Nu Smile, USA), Bioflx crowns group (n = 10, Nu Smile, USA) and Stainless Steel crowns group (n = 10, Nu Smile, USA). The crowns were cemented onto standardized acrylic resin dies and subjected to thermomechanical aging. Vertical marginal gap measurements were obtained using a USB digital microscope with an integrated camera, while fracture resistance was assessed with a universal testing machine. Data were analyzed for outliers and tested for normality using the Shapiro-Wilk or Kolmogorov-Smirnov tests, with statistical significance set at 0.05.

RESULTS

Significant differences were observed in the vertical marginal gaps among the groups after cementation and thermomechanical aging (P = 0.013 and P = 0.001, respectively). Zirconia crowns exhibited the largest average marginal gap, followed by Bioflx and Stainless Steel crowns. Stainless steel crowns demonstrated the highest fracture resistance, followed by Bioflx crowns, while Zirconia crowns showed the lowest.

CONCLUSIONS

Bioflx crowns exhibit the largest vertical marginal gap but show greater fracture resistance compared to Zirconia crowns, although they are still less resistant than Stainless Steel crowns after undergoing thermomechanical aging.

Success rate of all-ceramic FPDs depending on the time of restoration between 2011 and 2023

PURPOSE

Studies about success of FPDs (fixed partial dentures) mostly include restorations built by different clinicians. This results in limited comparability of the data. The aim of this study was to evaluate complications of all-ceramic FPDs built by 1 dentist between 2011 to 2023.

MATERIALS AND METHODS

342 all-ceramic FPDs were observed during follow-up care. 48 patients received 262 single crowns, 59 bridges and 21 veneers. Because of the different lengths of the bridges, units were defined as restored or replaced tooth. 465 units performed by the same dentist from Nov 2011 to Nov 2022 were included. Influencing factors "restoration", "construction", "abutment", "localization", "vitality" and "application period" were evaluated using Kaplan-Meier Analysis and Log-Rank Tests.

RESULTS

406 units (87.3 %) showed no complication. 7 correctable chippings (1.5 %) and 10 recementable decementations (2.1 %) occurred. Six decemented units got lost (1.3 %). 21 units failed due to fatal fracture (4.5 %). Crown margin complications, such as secondary caries, occurred in 15 units (3.2 %). Comparing the influencing factors resulted in higher complication rates of veneers (P < .001), of monolithic ceramics (P ≤ .050) and of molar-restorations (P = .047). The application period had no influence on the success and survival rate.

CONCLUSION

Overall, all-ceramic FPDs showed good clinical results. Although less complications were observed with modern restorations, these more often led to complete failure. To generate evidence-based recommendations, further studies are needed to evaluate the mid- and short-term success and survival of current all-ceramic restorations.

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.

Fatigue behavior of multilayer ceramic structures in traditional and reverse layering designs

PURPOSE

This study evaluated the fatigue failure load (FFL) and the number of cycles for fatigue failure (CFF) of traditional (porcelain layer up) and reversed (zirconia layer up) designs of porcelain-veneered zirconia samples prepared with heat-pressing or file-splitting techniques.

MATERIALS AND METHODS

Zirconia discs were prepared and veneered with heat-pressed or machined feldspathic ceramic. The bilayer discs were bonded onto a dentin-analog according to the bilayer technique and sample design: traditional heat-pressing (T-HP), reversed heat-pressing (R-HP), traditional file-splitting with fusion ceramic (T-FC), reversed file-splitting with fusion ceramic R-FC), traditional file-splitting with resin cement (T-RC), and reversed file-splitting with resin cement (R-RC). The fatigue tests were performed using the stepwise approach at 20 Hz, 10,000 cycles/step, step-size of 200 N starting at 600 N, and proceeding until failure detection or up to 2600 N if enduring. The failure modes (from radial and/or cone cracks) were analyzed in a stereomicroscope.

RESULTS

The reversed design decreased the FFL and CFF of bilayers prepared with heat-pressing and file-splitting with fusion ceramic. The T-HP and T-FC reached the highest results, which were statistically similar between them. The bilayers prepared by the file-splitting with resin cement (T-RC and R-RC) were similar to the R-FC and R-HP groups regarding FFL and CFF. Almost all reverse layering samples failed by radial cracks.

CONCLUSIONS

The reverse layering design did not improve the fatigue behavior of porcelain veneered zirconia samples. The three bilayer techniques behaved similarly when used in the reversed design.

Effect of low-temperature degradation and sintering protocols on the color of monolithic zirconia crowns with different yttria contents

This study investigated the effects of low-temperature degradation (LTD) on the L*, a*, and b* values of highly translucent zirconia crowns. Four types of zirconia disks with different yttria contents (IPS e.max ZirCAD LT, IPS e.max ZirCAD MT, IPS e.max ZirCAD MT Multi, IPS e.max ZirCAD Prime, Ivoclar) and two shades (A2 and BL) were used. A crown was manufactured using four types of zirconia and LTD treated. Color measurements were performed, and the color difference (ΔE00) before and after LTD was calculated. The microstructure was determined through X-ray fluorescence and X-ray diffractometry. Highly translucent zirconia crowns showed greater changes in the a* and b* values than in the L* value after LTD, regardless of the shade. The Multi2 crowns exhibited a discernible color change due to the LTD treatment. The X-ray fluorescence results did not reveal any apparent change in the microstructure between sintering programs for all zirconia specimens.

Impact of restoration thickness and tooth shade background on the translucency of zirconia laminate veneers: An in vitro comparative study

Purpose

Our in vitro comparative study aimed to investigate the impact of thickness and tooth shade background on the translucency of highly translucent zirconia veneers.

Materials and Methods

A total of 75 5Y-TZP zirconia veneers of shade A1 were fabricated with thicknesses of 0.50 mm (n = 25), 0.75 mm (n = 25), and 1.0 mm (n = 25). The translucencies were measured on composite resin teeth with shades A1, A2, A3, A3.5, and A4 using a digital color imaging spectrophotometer. Data were analyzed using ANOVA and post hoc Tukey's test (p < 0.05).

Results

The translucency values were optimal for the veneers placed over the substrate teeth with shades A1 and A2, regardless of the veneer thickness. Additionally, veneers with a thickness of 0.50 mm exhibited significantly higher translucency than those with thicknesses of 0.75 mm and 1.0 mm.

Conclusions

Our study demonstrated that the translucency of the highly translucent zirconia veneers was influenced by both veneer thickness and tooth shade background. The optimal veneer thickness for achieving the highest translucency was 0.50 for the veneers with A1 and A2 shades placed over the substrate teeth.

Clinical Relevance

The optimal thickness for achieving the highest translucency of the highly translucent zirconia laminate veneers was 0.50 mm for the veneers with A1 and A2 shades placed over the substrate teeth. Clinicians and dental technicians could consider this when selecting materials for aesthetic restorations.

The effect of preparation design on fracture resistance of endodontically treated maxillary premolars restored with lithium disilicate computer-aided design/computer-aided manufacturing endocrowns: An in vitro study

Purpose

This study aimed to assess the effect of preparation design on fracture resistance (FR) of endodontically treated maxillary premolars restored with lithium disilicate (LDS) endocrowns fabricated by the computer-aided design/computer-aided manufacturing (CAD/CAM) technology.

Materials and Methods

In this in vitro, experimental study, 30 sound maxillary premolars were randomly assigned to three groups (n = 10) of control (no preparation), endocrown preparation with butt-joint design without ferrule, and endocrown preparation with ferrule (shoulder design with 1 mm height). After restoration fabrication and cementation, the teeth underwent thermocycling, were mounted with 45° angle, and subjected to compressive load in a universal testing machine to measure their FR. The mode of failure was also determined under a stereomicroscope. Data were analyzed using one-way ANOVA and Tukey's test (α =0.05).

Results

The shoulder group showed the highest FR (1768.98 ± 386.1 N). The difference in FR was statistically significant among the three groups (P < 0.05). Pairwise comparisons revealed that the shoulder group had significantly higher FR than the butt-joint (P = 0.001) and control (P = 0.009) groups. However, the difference in FR between the butt-joint and control groups was not significant (P = 0.75). The mode of failure was not significantly different among the three groups (P > 0.05).

Conclusions

Preparation design had a significant effect on FR of endodontically treated maxillary premolars restored with LDS CAD/CAM Endocrowns, such that addition of a short axial wall in shoulder group significantly increased the FR of endocrowns.

Fracture resistance of prefabricated versus custom-made zirconia crowns after thermo-mechanical aging: an in-vitro study

BACKGROUND

Prefabricated zirconia crowns for a young permanent molar is a child-friendly solution for restoring a permanent molar at a young age. This in-vitro study aimed to compare the fracture resistance of prefabricated versus custom-made permanent molar crowns.

METHODS

16 identical resin dies were fabricated to receive permanent molar zirconia crowns, dies were divided into 2 groups, 1) received perfricated crowns, 2) custom-made crowns. Thermo-dynamic cycling was performed to simulate 6 months in the oral cavity, Fracture resistance of each group was assessed by applying increasing load till fracture. Data were tested for normality using Shapiro-Wilk and Levene's tests. Data were analyzed using independent t test.

RESULTS

No statistically significant difference was found between fracture resistance of prefabricated and custom-made crowns (1793.54 ± 423.82) and (1987.38 ± 414.88) respectively. 3 crowns of the custom-made group fractured with the underlying die, versus zero dies fractured in the prefabricated group.

CONCLUSIONS

Prefabricated permanent molars zirconia crowns can perform as well as custom-made crowns for an adult in terms of fracture resistance, it is suitable for children and can withstand the occlusal forces of an adult.

The influence of aging on the fracture load of milled monolithic crowns

Background

This in-vitro study was conducted to assess the effect of aging on the fracture load of molar crowns fabricated with monolithic CAD/CAM materials.

Methods

The crown restorations were produced from Cerasmart, Vita Enamic, and IPS e.max CAD blocks. Aging was applied to the 10 samples each of monolithic CAD/CAM materials (n = 10). Dual-axis chewing simulator (50 N, 1.1 Hz, lateral movement: 1 mm, mouth opening: 2 mm, 1,200,000 cycles) and thermocycling (± 5–55 °C, 6000 cycles) were applied as an aging procedure. 10 samples each of monolithic CAD/CAM materials without aging (n = 10) were considered the control group. 6 tested groups were obtained. Then, all samples were evaluated in a universal testing machine to determine the fracture loading values’.

Results

There was not a statistically significant difference between the fracture load values before and after aging for all samples of Cerasmart, Vita Enamic, and IPS e.max CAD (p > 0.005). In a comparison of the monolithic materials together, a statistically significant difference was found between the fracture load values of IPS e.max CAD and Vita Enamic crowns before aging (p = 0.02). Also, Vita Enamic crowns (1978,71 ± 364,05 N) were found different from the IPS e.max CAD (p = 0.005) and Cerasmart crowns (p = 0.041) after aging.

Conclusions

Dynamic aging with 1.200.000 cycles was found to have no effect to fracture loading on milled Cerasmart, Vita Enamic, and IPS e.max CAD monolithic crowns.

Physical, Optical, and Mechanical Properties of Ceramic Materials after Coffee Immersion and Evaluation of Cleaning Impact with Different Oral Hygiene Tools

This study aimed to evaluate the effect of three oral hygiene tools, a regular toothbrush, an electronic toothbrush, and mouthwash, on the color stability of three different computer-aided design (CAD) and computer-aided manufactured (CAM) ceramic blocks. Feldspathic ceramic (Vita Triluxe Forte), hybrid resin ceramic (Vita Enamic), and lithium disilicate glass-ceramic (IPS e.max CAD) were used in this study. A CAD/CAM system and 81 (27 of each material) samples of ceramic blocks were used. All samples were immersed in black coffee for 15 days, and the coffee was changed twice per day. Using a spectrophotometer probe, samples on a grey background were scanned, and physical properties like surface hardness and depth were measured using interferometry and a 3D non-contact surface metrology. After 30 days of application of oral hygiene tools, instruments were used to measure various physical, mechanical, and optical properties. Vita Triluxe had the highest average color variation values (ΔE₀₀) after 15 and 30 days of immersion in coffee in both regular and electronic toothbrushes. Moreover, IPS e.max CAD had the least ΔE₀₀ values with no significant differences among the groups. The surface roughness (Ra) of the Vita Enamic ceramic increased when using a regular toothbrush, and the surface height (Rz) for the Vita Enamic ceramic increased when an electronic toothbrush was used. IPS e.max CAD had the greatest modules of elasticity forces, and Vita Triluxe Forte had the lowest when used with a regular toothbrush. The ΔE₀₀ values of the tested materials were minimally increased or decreased after 30 days of cleaning, and all were clinically acceptable. Ra and Rz were the highest for Vita Enamic in comparison to the other groups. The highest percentage in IPS e.max CAD was associated with a type 1 fracture, whereas type 3 was predominantly observed with Vita Enamic, and type 2 in the Vita Triluxe group without significant differences.

Fatigue and Fracture Resistance Testing of Polyether Ether Ketone (PEEK) Implant Abutments in an Ex Vivo Chewing Simulator Model

Polyether ether ketone (PEEK) has been introduced into implant dentistry as a viable alternative to current implant abutment materials. However, data on its physico-mechanical properties are still scarce. The present study sought to shed light on this topic utilizing an ex vivo chewing simulator model. A total of 48 titanium two-piece implants were allocated into three groups (n = 16 per group): (1) implants with PEEK abutments and an internal butt-joint connection (PBJ), (2) implants with PEEK abutments and an internal conical implant-abutment connection (PC), and (3) implants with zirconia abutments and an internal butt-joint connection (ZA). All abutments were restored with a non-precious metal alloy crown mimicking the upper right central incisor. A dynamic chewing simulation of half (n = 8) of the specimens per group was performed with 5 × 106 cycles and a load of 49 N at a frequency of 1.7 Hz with thermocycling between 5 and 55 °C. The other eight specimens served as unloaded controls. Surface roughness, implant-abutment connection microgaps (IACMs), and the titanium base-abutment interface microgaps (TAIMs) in the loaded groups were evaluated. Finally, a quasi-static loading test was performed in a universal testing machine with all samples to evaluate fracture resistance. Overall, 23 samples survived the artificial chewing process. One abutment screw fracture was observed in the PC group. The ZA group showed higher surface roughness values than PEEK abutments. Furthermore, ZA revealed lower TAIM values compared to PEEK abutments. Similarly, ZA was associated with lower IACM values compared to PBJ. Fracture loads/bending moments were 1018 N/704 N cm for PBJ, 966 N/676 N cm for PC, and 738 N/508 N cm for ZA, with no significant differences compared to the unloaded references. Artificial loading did not significantly affect fracture resistance of the examined materials. PEEK abutments were associated with better load-bearing properties than zirconia abutments, although they showed higher microgap values. PEEK abutments could, therefore, be feasible alternatives to zirconia abutments based on the present ex vivo findings resembling 20 years of clinical service.

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.

Load-to-Failure Resistance and Optical Characteristics of Nano-Lithium Disilicate Ceramic after Different Aging Processes

The aim of this study was to compare the load-to-failure resistance and optical properties of nano-lithium disilicate (NLD) with lithium disilicate (LDS) and zirconia-reinforced lithium silicate (ZLS) in different aging processes. Thirty crowns were milled from NLD, LDS, and ZLS (n = 10). All crowns were subjected to thermomechanical aging and loaded until catastrophic failure. Ten specimens from each material were prepared in two different thicknesses (0.7 mm and 1.5 mm, n = 5), and color coordinates were measured before and after coffee thermocycling. Color differences (ΔE00) and relative translucency parameter (RTP) were calculated. Data were analyzed by using ANOVA and Bonferroni-corrected t-tests (α = 0.05). ZLS had the highest load-to-failure resistance (p ≤ 0.002), while the difference between LDS and NLD was nonsignificant (p = 0.776). The interaction between material type and thickness affected ΔE00 (p < 0.001). Among the 0.7 mm thick specimens, ZLS had the lowest ΔE00 (p < 0.001). Furthermore, 1.5 mm thick ZLS had lower ΔE00 than that of 1.5 mm thick LDS (p = 0.036). Other than ZLS (p = 0.078), 0.7 mm thick specimens had higher ΔE00 (p < 0.001). The interaction between material type, thickness, and thermocycling affected RTP (p < 0.001). Thinner specimens presented higher RTP (p < 0.001). NLD and LDS had higher RTP than ZLS (p ≤ 0.036). However, 0.7 mm thick specimens had similar RTP after coffee thermocycling (p ≥ 0.265). Coffee thermocycling reduced the RTP values of 0.7 mm thick NLD (p = 0.032) and LDS (p = 0.008). NLD may endure the occlusal forces present in the posterior region. However, long-term coffee consumption may impair the esthetics of restorations particularly when thin NLD is used.

The effect of nonthermal argon plasma surface treatment on the fracture resistance of monolithic zirconia restorations containing tetragonal and cubic grains

PURPOSE

The aim of this study was to investigate the effect of nonthermal argon plasma (NP) surface treatment on the fracture resistance of monolithic zirconia restorations with different microstructures.

METHODS

Twenty restorations were prepared from each of two tetragonal and two cubic zirconia materials (80 restorations in total). The restorations were then divided into two subgroups (n = 10) for each material according to the surface treatment applied: air abrasion or NP. The surface topography of the treated groups was examined using a scanning electron microscope. All restorations were fixed to metal dies with resin cement, subjected to thermal cycling, and then underwent fracture resistance testing with a universal testing device. Two-way ANOVA and Bonferroni tests were used for statistical analysis of the data (α = 0.05).

RESULTS

The type of surface treatment and the type of zirconia material were shown to significantly affect the fracture resistance of the restorations. The air-abraded groups showed significantly higher fracture resistance (N) than the NP groups (P < 0.001).

CONCLUSION

The results of this study suggest that air abrasion surface treatment has a more favorable effect on the fracture resistance of tetragonal and cubic zirconia restorations than NP surface treatment.

In Vitro Fatigue and Fracture Load of Monolithic Ceramic Crowns Supported by Hybrid Abutment

Objective:

This study evaluated the performance of zirconia and lithium disilicate crowns supported by implants or cemented to epoxy resin dies.

Methods:

Eigthy zirconia and lithium disilicate crowns each were prepared and assigned in four groups according to the crown material and supporting structure combinations (implant-supported zirconia, die-supported zirconia, implant-supported lithium disilicate, and die-supported lithium disilicate). Ten crowns in each group acted as control while the rest (n=10) underwent thermocycling and fatigue with 100 N loading force for 1.5 million cycles. Specimens were then loaded to fracture in a universal testing machine. Data were analysed using one-way ANOVA and Tukey multiple comparison test with a 95% level of significance.

Results:

No implants or crown failure occurred during fatigue. The mean fracture load values (control, fatigued) in newton were as follows: (4054, 3344) for implant-supported zirconia, (3783, 3477) for die-supported zirconia, (2506, 2207) for implant-supported lithium disilicate, and (2159, 1806) for die-supported lithium disilicate. Comparing the control with the corresponding fatigued subgroup showed a significantly higher fracture load mean of the control group in all cases. Zirconia showed a significantly higher fracture load mean than lithium disilicate (P=0.001, P<0.001). However, comparing crowns made from the same material according to the supporting structure showed no significant difference (P=0.923, P=0.337).

Conclusion:

Zirconia and lithium disilicate posterior crowns have adequate fatigue and fracture resistance required for posterior crowns. However, when heavy fatigue forces are expected, zirconia material is preferable over lithium disilicate. Zirconia and lithium disilicate implant-supported crowns cemented to hybrid abutments should have satisfactory clinical performance.

Spectrophotometric study determining staining tendency in different restorative materials (longitudinal in vitro study)

Aim

Our aim was to measure the discolouration degrees in a packable composite, zircon, ceramic, a flowable composite, and GIC (glass isomer cement) and to determine their tendencies to discolour to provide guidance to dentists and prosthodontist for choosing proper materials for cases in which aesthetics is the main treatment goal.

Materials and methods

Sixty discs were fabricated from the composite, zircon, ceramic, the flowable composite, and GIC, and natural teeth were the control group. The shades were recorded using the Ivoclar Vivadent Shade Guide, and readings were recorded from a Vita Easyshade 4.0 spectrophotometer before immersion, after 1 week, 2 weeks, 3 weeks, and 24 weeks of immersion in coffee. The analysis was performed using a SPSS paired t-test and CIE 76 formula.

Results

The ceramic had a starting shade of B1 and kept the same colour throughout the testing period. Zircon had a starting shade of A3 and transitioned to B3 by the second week. The composite had a shade of A1, and after the first week, it was A4; in the second week and afterwards, it was C4. The flowable composite had a starting shade of A1, and after one week, the shade was B3, and then after one more week A3.5; after five months, it was A4.

Conclusion

The ceramic showed no change, making it ideal for aesthetic regions and anterior replacements. Zircon had the second-highest colour stability, whereas all the other materials showed variable degrees of colour and surface changes, making them not ideal choices for anterior restorations. Thus, this information can aid choices for aesthetic regions to provide the highest longevity.

Survival and complications of monolithic ceramic for tooth-supported fixed dental prostheses: A systematic review and meta-analysis

STATEMENT OF PROBLEM

Although recent studies have reported the success of implant-supported monolithic restorations, consensus on the use of monolithic ceramic restorations is lacking.

PURPOSE

The purpose of this systematic review and meta-analysis was to evaluate the survival and biological and technical complication rates of monolithic single crowns and fixed partial dentures (FPDs).

MATERIAL AND METHODS

An electronic search was conducted by 2 independent authors on the PubMed/MEDLINE, Scopus, and Cochrane Library databases. The Newcastle-Ottawa scale and Cochrane risk of bias tool were used to assess the quality and risk of bias of the included studies. Meta-analysis was performed by using the R software program.

RESULTS

The search identified 763 articles, 18 of which met the eligibility criteria. A total of 15 studies evaluated monolithic ceramic single crowns, and 4 studies evaluated FPDs. The studies included 1061 monolithic single crowns (524 lithium disilicate, 461 zirconia, and 76 polymer-infiltrated ceramic network [PICN]) and 104 FPDs (36 lithium disilicate and 68 zirconia). Meta-analysis of single-arm studies indicated the proportion of survival, biological, and technical complication rates of 1% (95% confidence interval [CI]: 0% to 3%), 1% (CI: 0% to 4%), and 2% (CI: 1% to 4%), respectively, for single crowns, independent of ceramic material, and 3% (CI: 0% to 34%), 5% (CI: 1% to 21%), and 5% (CI: 1% to 21%) for FPDs, respectively. Only 5 studies performed a direct comparison between monolithic and veneered ceramic restorations, and no significant difference was observed in terms of survival (risk ratio [RR]: 0.68; CI: 0.25-1.91; P=.96), biological (RR: 0.69; CI: 0.31-1.53; P=.35), and technical complication rates (RR: 0.87; CI: 0.40-1.88; P=.29).

CONCLUSIONS

The use of monolithic ceramic can be considered a favorable treatment for tooth-supported single crowns and FPDs, with high survival and low complication rates. However, further randomized controlled trials are needed to reassess these clinical performances, mainly by comparing them with the performance of veneered restorations.

Minimal tooth preparation for posterior monolithic ceramic crowns: Effect on the mechanical behavior, reliability and translucency

OBJECTIVE

Despite the increased use of monolithic crowns, their performance has yet to be determined when the minimal tooth preparation (MTP) principle is considered. The goal of this study was to evaluate the effect of MTP on the mechanical behavior, reliability and translucency of posterior monolithic ceramic crowns.

METHODS

Dentin analogues were machined using two preparation designs (0.5 or 1 mm reduction) to receive first molar crowns in order to evaluate the monolithic crown performance. Next, 126 crowns were divided (21/g) according to the material (High translucent zirconia - YZHT, Zirconia reinforced lithium silicate - ZLS and Hybrid ceramic - HC) and thickness (0.5 or 1 mm). Tensile stress concentration was calculated using the finite element method. The crowns were adhesivelly cemented and step stress fatigued to calculate reliability for missions at 600 and 1000 N. Translucency was analyzed in 10 discs of each material and thickness.

RESULTS

Higher stress concentration was found in thinner crowns and those with higher elastic modulus. YZHT crowns were suspended when fatigue reached 1500 N load, thus 1-parameter Weibull was used to analyze the data. Reliability was only affected by thickness at 1000 N. ZLS.5 showed lower survival than HC.5, which was similar to the groups that presented 100% survival. YZHT showed the highest strength and data scattering. ZLS1 (22.3 ± 1.4) presented higher translucency than HC1 (19.2 ± 0.6) and YZHT1 (12.0 ± 2.9), whereas ZLS.5 and HC.5 were similar to each other (26.5 ± 2.3, 26.7 ± 2.2) and superior to YZHT.5 (12.7 ± 1.2).

SIGNIFICANCE

HC.5 combined high reliability and translucency with low stress concentration, yielding better crown performance and tooth preservation.

Prospective study of monolithic zirconia crowns: clinical behavior and survival rate at a 5-year follow-up

Purpose To evaluate the clinical behavior and survival of full coverage monolithic zirconia crowns on posterior teeth over a 5-year follow-up.Methods Fifty patients were recruited and underwent restoration with a Lava Plus monolithic zirconia crown (Lava™ Frame Zirconia, 3M Espe, Germany) on premolars or molars. Patients were monitored over a 5-year follow-up (2014-19), recording any biological and/or mechanical complications; these data were used to estimate the crowns' success rate. Periodontal clinical parameters were recorded (pocket probing depth (PPD), plaque index (PLI), bleeding on probing (BOP), and gingival recession (GR)). Wear to the zirconia crowns and antagonist teeth were also evaluated with Geomagic software (3D Systems, U.S.A.). Patients' satisfaction with treatment was evaluated in a questionnaire.Results For the 50 monolithic zirconia crowns analyzed, the survival rate was 98% after 5 years. Only 6% of the crowns presented some type of complication (two debonding and one root fracture). No fracture or fissures were detected. GR and BOP were the only clinical parameters found to be significantly greater around teeth restored with crowns. The monolithic zirconia crowns suffered less wear than the enamel of antagonist teeth. Patient's general satisfaction with treatment was high.Conclusions Monolithic zirconia crowns on posterior teeth are a highly predictable treatment option, with a high survival rate. The single treatment failure was due to a biological complication arising from root fracture. This treatment may be recommended as a treatment that conserves dental structure, and requires minimal dental preparation.

Effect of glazing application side and mechanical cycling on the biaxial flexural strength and Weibull characteristics of a Y-TZP ceramic

Glaze application on monolithic zirconia (Y-TZP) can be a practical approach to improve the mechanical properties of this material.

Biomechanical behavior of endocrown restorations with different CAD-CAM materials: A 3D finite element and in vitro analysis

STATEMENT OF PROBLEM

The performance of endocrowns fabricated with different types of computer-aided design and computer-aided manufacturing (CAD-CAM) materials is unclear.

PURPOSE

The purpose of this finite element analysis (FEA) and in vitro study was to compare and evaluate the stress distribution, failure probability, and fracture resistance of endodontically treated teeth restored with endocrowns from CAD-CAM milling blocks including ceramic, polymer-infiltrated ceramic (PICN), and composite resin.

MATERIAL AND METHODS

An endodontically treated first mandibular molar restored with an endocrown was modeled by using a CAD software program and imported into an FEA software program. The model was duplicated and received restorations made from CAD-CAM blocks: Vita Suprinity (VS), IPS e.max CAD (EMX), Vita Enamic (VE), Lava Ultimate (LU), and Grandio blocs (GR). Stress distributions under axial and oblique loading were analyzed. The Weibull function was combined with the FEA results to predict long-term failure probability. The mechanical failure behavior of endocrowns manufactured with these materials was tested by using a universal testing machine. Load-to-failure was recorded, and fractured specimens were subjected to fractography. The data were analyzed by 1-way ANOVA and the post hoc Tukey test (α=.05).

RESULTS

The models of GR and LU exhibited a more even stress distribution. The Weibull analysis revealed that 5 models performed in a similar manner under normal occlusal forces, while LU and VE models achieved the highest probabilities during clenching. The fracture loads of GR (3808 ±607 N) were significantly higher than those of other materials (P<.05). More favorable failure modes were observed in the GR and VE groups. Fractography showed a greater probability of compression curls and arrest lines in the endocrowns of VE, LU, and GR groups.

CONCLUSIONS

When restoring endodontically treated teeth, endocrown fabricated with composite resin exhibited a more uniform stress distribution and higher fracture resistance. More evidence from long-term clinical studies is needed to verify this effect.

Strength and aging resistance of monolithic zirconia: an update to current knowledge

New zirconia compositions with optimized esthetic properties have emerged due to the fast-growing technology in zirconia manufacturing. However, the large variety of commercial products and synthesis routes, make impossible to include all of them under the general term of “monolithic zirconia ceramics”. Ultra- or high translucent monolithic formulations contain 3–8 mol% yttria, which results in materials with completely different structure, optical and mechanical properties. The purpose of this study was to provide an update to the current knowledge concerning monolithic zirconia and to review factors related to strength and aging resistance. Factors such as composition, coloring procedures, sintering method and temperature, may affect both strength and aging resistance to a more or less extend. A significant reduction of mechanical properties has been correlated to high translucent zirconia formualtions while regarding aging resistance, the findings are contradictory, necessitating more and thorough investigation. Despite the obvious advantages of contemporary monolithic zirconia ceramics, further scientific evidence is required that will eventually lead to the appropriate laboratory and clinical guidelines for their use. Until then, a safe suggestion should be to utilize high-strength partially-stabilized zirconia for posterior or long span restorations and fully-stabilized ultra-translucent zirconia for anterior single crowns and short span fixed partial dentures.

Fracture resistance of monolithic and veneered all-ceramic four-unit posterior fixed dental prostheses after artificial aging

This study compared the fracture resistance of monolithic and veneered all-ceramic four-unit posterior fixed dental prostheses (FDPs) generated by computer-aided design/computer-aided manufacturing (CAD/CAM) after aging in a mastication simulator. Four-unit FDPs were designed from six different all-ceramic systems: 1) monolithic lithium disilicate (M-E), 2) monolithic zirconia (M-TZI), 3) veneered zirconia by conventional layering (V-L), 4) veneered zirconia by lithium disilicate pressing (V-P), 5) veneered zirconia by lithium disilicate fusing (CAD-F-E), and 6) veneered zirconia by feldspathic ceramic cementing (CAD-C-CB). The specimens were divided into control and aging groups (n = 10 per group). The aging process included both thermocycling and mechanical loading and was followed by fracture resistance testing. All specimens in the M-E, M-TZI, and V-L groups survived; however, all specimens in the V-P group were fractured during artificial aging. The highest fracture resistance values were observed in the M-TZI group. According to the fracture resistance test, connector fractures were the most frequent type of failure. M-TZI and M-E FDPs revealed no failures during aging and showed higher fracture resistance than the veneered groups. Among the veneered zirconia framework groups, V-L FDPs showed the highest success rate during aging, while the fracture resistance was similar among all the veneered zirconia groups.

Fracture resistance of different implant supported ceramic abutment/crown systems

Purpose

The purpose of this study was to investigate the fracture resistance and failure modes of different non-aged and aged abutment/crown systems.

Materials and methods

One hundred dental implants (diameter 4.3 mm and length 11.5 mm) were restored with five abutment/crown systems: G1: a lithium disilicate hybrid abutment crown, G2: a lithium disilicate crown cemented on a lithium disilicate hybrid abutment, G3: a lithium disilicate crown cemented on a zirconia hybrid abutment, G4: a direct veneer porcelain layering on a zirconia hybrid abutment, and G5: a lithium disilicate crown cemented on a prefabricated all-zirconia abutment. Each group was divided into two groups (n=10) as control (non-aged) and thermomechanically aged. The fracture resistance test was performed. Failures during the aging process and after the fracture resistance test were examined.

Results

Both of the factors (restoration type and aging) affected the fracture resistance values and there was not an interaction between the factors (p>0.05). When fracture resistance values were compared regardless of aging, the highest values were observed in G3 and G4, respectively (p<0.05). When comparing the fracture resistance values, regardless of the restoration type, the aged group showed a significant lower fracture resistance value than control group (p<0.05).

Conclusion

A titanium base enhanced the fracture resistance of zirconia abutments. Thermomechanical aging decreased the fracture resistance of the tested ceramic abutment/crown systems. The major failure mode was the abutment fracture.

Assessment of marginal adaptation and fracture resistance of endocrown restorations utilizing different machinable blocks subjected to thermomechanical aging

OBJECTIVE

This in vitro study was conducted to assess the marginal adaptation and fracture resistance of computer aided design/computer aided manufacturer (CAD-CAM) fabricated endocrowns restoring endodontically treated molars using different machinable blocks with thermomechanical loading protocols.

MATERIALS AND METHODS

Devitalized mandibular molars were prepared in a standardized way and divided into 4 groups (n = 10) to receive CAD/CAM fabricated endocrowns using four materials (Lithium disilicate ceramics, polymer infiltrated ceramics, zirconia-reinforced lithium silicate ceramics and resin nanoceramics. Marginal gaps (µm) were measured using stereomicroscope before cementation and after cementation. After thermomechanical aging, marginal gap measurements were repeated, and then fracture resistance test was performed. Two-way analysis of variance (ANOVA) and Tukey HSD multiple comparisons were used to assess the effect of material on the marginal gap before, after cementation, and after thermomechanical aging. One Way ANOVA was used to assess the effect of material on the fracture resistance.

RESULTS

The difference between marginal gaps values of the tested materials was statistically insignificant but with significant increase after cementation and after thermomechanical aging. Cerasmart endocrowns showed the highest mean fracture load value (1508.5 ± 421.7N) with statistically significant difference than Vita Enamic endocrowns and Celtra Duo.

CONCLUSION

The tested materials showed marginal vertical gap readings within the limits of clinically acceptable standards. Resin nanoceramics and lithium disilicate showed the highest values of fracture resistance followed by polymer infiltrated ceramics favoring their use for endocrown restorations.

CLINICAL SIGNIFICANCE

The mechanical behavior of ceramic materials varies with the variation of their structure and mechanical properties. Accordingly, further investigation is always needed to explore the biomechanical behavior of recent materials when used as endocrowns before clinical trials.

Majeed M. Comparative Evaluation of the Fracture Strength of Monolithic Crowns Fabricated from Different all-ceramic CAD/CAM Materials (an in vitro study)

The objective of this in vitro study was to evaluate and compare the fracture strength of monolithic crowns fabricated from five different all-ceramic CAD/CAM materials (lithium disilicate, zirconia, reinforced composite, hybrid dental ceramic, and zirconia-reinforced lithium silicate) using single load to failure test. Forty sound human maxillary first premolar teeth extracted for orthodontic purposes were selected for use in this study. Teeth were prepared according to a standard protocol with 1 mm deep chamfer finishing line, 4 mm axial height with planer occlusal reduction and 6º total convergence angle. Teeth were then divided into five groups of eight teeth each according to the material used for the fabrication of the monolithic crowns as follow: Group A: Crowns fabricated from lithium disilicate (IPS e.max CAD, Ivoclar Vivadent), Group B: Crowns fabricated from zirconia (CEREC Zirconia, Dentsply Sirona), Group C: Crowns fabricated from reinforced composite (BRILLIANT Crios, COLTENE), Group D: Crowns fabricated from hybrid dental ceramic (VITA ENAMIC, VITA Zahnfabric), Group E: Crowns fabricated from zirconia-reinforced lithium silicate (CELTRA DUO, Dentsply Sirona). Teeth of all groups were then scanned with CEREC Omnicam digital intraoral scanner and the crowns were then designed using CEREC Premium software (version 4.4.4) and milled using CEREC MC XL milling unit. Post-milling, crowns of each group were subjected to either a firing procedure or to a polishing only according to the manufacturer's instructions of each material. The internal surfaces of the crowns of each group were then subjected to surface treatment according to the manufacturer's instructions of each material and the crowns were then cemented on their respective teeth using a universal dual-cured adhesive resin cement (Duo-Link Universal, Bisco Inc.). All teeth with the cemented crowns were then stored in deionized distilled water at room temperature for 24 hours before testing. All samples were then subjected to compressive axial loading until fracture in computer-controlled universal testing machine (Zwick Z010, Ulm, Germany) at a crosshead speed of 0.5 mm/min. The data were statistically analyzed using one-way ANOVA test and LSD test at a level of significance of 0.05. The results of this study showed that the highest mean value of fracture strength was recorded by Group B (2337.37), followed by Group C (1880.59), Group E (1404.49), Group A (1085.39) and Group D (767.06), respectively with statistically highly significant differences among the different groups (p<0.01). From the results of this study, it seems that the differences in the chemical composition and microstructure of the tested all-ceramic CAD/CAM materials may be responsible for the differences in the fracture strength of the fabricated crowns.

Effect of shading technique and thickness on color stability and translucency of new generation translucent zirconia

OBJECTIVE

To evaluate the effect of shading technique and thickness on the color stability and translucency of translucent zirconia after coffee thermocycling.

METHODS

Specimens in different thicknesses (1; 1.5; 2 mm) (n = 4 for each thickness) were sectioned from translucent preshaded zirconia (Pre) and externally shaded zirconia (Ext). After sintering, specimens were glazed and subjected to 10,000 thermocycling in coffee solution. The color coordinates of specimens were measured with a spectroradiometer before and after coffee thermocyling. Color differences and relative translucency parameter (RTP) values were calculated with CIEDE2000 color difference and TP_CIEDE2000 formulas. ANOVA was used to analyze the CIEDE2000 color difference and RTP values (α = 0.05).

RESULTS

According to 2-way ANOVA, no significant effect of shading technique and thickness on the color difference values was found (P > .05). According to 3-way ANOVA, a significant interaction between the shading technique and thickness (P < .0001) was found for RTP. The RTP parameter decreased with the increase in the thickness. Ext specimens presented significantly higher RTP than Pre specimens (P < .0001), except for between Ext 1 mm and Pre 1 mm (P = .179).

CONCLUSIONS

Neither shading technique nor tested thicknesses affected the color of translucent zirconia. Shading technique and thickness affected the RTP of translucent zirconia. The RTP was inversely affected with the thickness of the material. Externally shaded zirconia presented higher RTP than preshaded zirconia for specimens thicker than 1 mm.

CLINICAL SIGNIFICANCE

Discoloration with coffee was insignificant for the tested translucent zirconia in tested thicknesses (1, 1.5, 2 mm). When a translucent restoration is intended, thinner externally shaded translucent zirconia restorations should be preferred instead of preshaded translucent zirconia.