Undermining of enamel as a mechanism of abfraction lesion formation: a finite element study

A novel porcine dentin-derived bone graft material provides effective site stability for implant placement after tooth extraction: a randomized controlled clinical trial

OBJECTIVES

Assessment of the clinical performance of a porcine dentin-derived particulate bone graft material for bone regeneration after tooth extraction with implant placement at 4 months, in comparison to a commercially available porcine bone-derived graft.

MATERIAL AND METHODS

This study was a randomized, parallel-group, semi-double-blinded clinical trial evaluating the clinical safety, tolerability, and performance of Ivory Dentin Graft™ in comparison with a commercial bone-derived material in alveolar ridge preservation following tooth extraction (registered at ClinicalTrials.gov, May 12th, 2017, Identifier NCT03150472). Extraction sites were grafted with test or comparator material and a titanium implant placed at 4 months after taking a graft site biopsy. Primary endpoints were the extent of new bone growth and bone-graft integration at 4 months.

RESULTS

The dentin graft material had statistically significantly more new bone formation (60.75% vs 42.81%, p = 0.0084, N = 20 vs 16), better bone-graft integration scores (good integration in 85% vs 40%, p = 0.0066), and higher mean radiodensity of the bone (981.5HU vs 727.7HU, p = 0.0011) at the graft site compared to the bone-derived material. The mean implant insertion torque force was similar for the dentin and bone materials (34.75 Ncm vs 34.06 Ncm). Titanium implant placement was successful in 95% of patients with the dentin graft material compared to 81.25% for the bone graft. Both materials had similar clinical safety and tolerability as determined by adverse events and local site reactions. Physician-assessed ease of grafting and ease of implant placement on a 10-point scale showed no statistical differences (8.78 vs 8.27, p = 0.2355; 8.05 vs 8.75, p = 0.1118, respectively).

CONCLUSIONS

A porcine dentin-derived bone graft material has clinical safety, tolerability, and performance for implant placement at 4 months after tooth extraction at least as good as a commercial bone-derived material.

CLINICAL RELEVANCE

The availability of porcine dentin-derived bone graft material allows wider use of dentin-derived material which has so far only been available in the form of autologous dentin from the patient's own teeth.

Fatigue and wear of human tooth enamel: A review

Human tooth enamel must withstand the cyclic contact forces, wear, and corrosion processes involved with typical oral functions. Furthermore, unlike other human tissues, dental enamel does not have a significant capacity for healing or self-repair and thus the longevity of natural teeth in the oral environment depends to a large degree on the fatigue and wear properties of enamel. The purpose of this review is to provide an overview of our understanding of the fatigue and wear mechanisms of human enamel and how they relate to in vivo observations of tooth damage in the complex oral environment. A key finding of this review is that fatigue and wear processes are closely related. For example, the presence of abrasive wear particles significantly lowers the forces needed to initiate contact fatigue cracking while subsurface fatigue crack propagation drives key delamination wear mechanisms during attrition or attrition-corrosion of enamel. Furthermore, this review seeks to bring a materials science and mechanical engineering perspective to fatigue and wear phenomena. In this regard, we see developing a mechanistic description of fatigue and wear, and understanding the interconnectivity of the processes, as essential for successfully modelling enamel fatigue and wear damage and developing strategies and treatments to improve the longevity of our natural teeth. Furthermore, we anticipate that this review will stimulate ideas for extending the lifetime of the natural tooth structure and will help highlight where our understanding is too limited and where additional research into fatigue and wear of human tooth enamel is warranted.

Noncarious cervical lesions: Morphology and progression, prevalence, etiology, pathophysiology, and clinical guidelines for restoration

PURPOSE

To synthesize the literature regarding noncarious cervical lesions (NCCLs) and propose clinical guidelines when lesion restoration is indicated.

MATERIAL AND METHODS

A PubMed search was performed related to NCCL morphology, progression, prevalence, etiology, pathophysiology, and restoration.

RESULTS

NCCLs form as either rounded (saucerlike) depressions with smooth, featureless surfaces that progress mainly in height or as V-shaped indentations that increase in both height and depth. Prevalence ranges from less than 10% to over 90% and increases with age. Common locations are the facial surfaces of maxillary premolars. They have a multifactorial etiology due to personal habits such as excessive horizontal toothbrushing and consumption of acidic foods and drinks. Occlusal factors have been identified as contributing to the prevalence of NCCLs in some studies, whereas other studies indicate there is no relationship. The concept of abfraction has been proposed whereby mechanical stress from occlusal loading plays a role in the development and progression of NCCLs with publications supporting the concept and others indicating it lacks the required clinical documentation. Regardless of the development mechanism, demineralization occurs and they are one of the most common demineralization diseases in the body. Treatment should be managed conservatively through preventive intervention with restorative treatment delayed until it becomes necessary due to factors such as lesion progression, impact on patient's quality of life, sensitivity, poor esthetics, and food collection may necessitate restoration. Composite resins are commonly used to restore NCCLs although other materials such as glass ionomer and resin-modified glass ionomer are also used. Sclerotic dentin does not etch like normal dentin and therefore it has been recommended to texture the dentin surface with a fine rotary diamond instrument to improve restoration retention. Some clinicians use mechanical retention to increase retention. Beveling of enamel is used to increase the bonding area and retention as well as enhance the esthetic result by gradually creating a color change between the restoration and tooth. Both multistep and single-step adhesives have been used. Dentin etching should be increased to 30 seconds due to the sclerotic dentin with the adhesive agent applied using a light scrubbing motion for 20 seconds but without excessive force that induces substantial bending of a disposable applicator. Both flowable and sculptable composite resins have been successfully used with some clinicians applying and polymerizing a layer of flowable composite resin and then adding an external layer of sculptable composite resin to provide enhanced resistance to wear. When caries is present, silver diamine fluoride has been used to arrest the caries rather than restore the lesion.

CONCLUSIONS

Noncarious cervical lesions (NCCLs) form as smooth saucerlike depressions or as V-shaped notches. Prevalence values as high as 90% and as low as 10% have been reported due to habits such as excessive toothbrushing and an acidic diet. Occlusal factors have been proposed as contributing to their presence but it remains controversial. Publications have both supported and challenged the concept of abfraction. They are one of the most common demineralization diseases in the body. Conservative treatment through prevention is recommended with restorative treatment delayed as long as possible. When treatment is needed, composite resins are commonly used with proposed restorative guidelines including texturing the sclerotic dentin, beveling the enamel, potential use of mechanical retention, 30 seconds of acid etching, and use of either multistep or single-step adhesives in conjunction with a light scrubbing motion for 20 seconds without excessive force placed on disposable applicators.

Fatigue Resistance of 3-Unit CAD-CAM Ceramic Fixed Partial Dentures: An FEA Study

PURPOSE

To estimate the fatigue life of 3-unit molar fixed partial dentures (FPDs) made from two different monolithic ceramic systems, zirconia cercon (ZC) and lithium disilicate (LD). The effect of the connector size on the fatigue resistance of the monolithic FPD was also investigated.

METHODS

Two models for the FPDs were built, a 3-unit all-ceramic and a porcelain-fused-to-metal. The porcelain-fused-to-metal FPD model was used as the control. Actual 3-unit FPDs (replacing the second lower premolar) were constructed using a computer aided design and computer-aided manufacturing (CAD-CAM) system. Finite element analysis (FEA) was executed. A hemispherical indenter was used to simulate occlusal load. The occlusal load phase of the chewing cycle was applied at the premolar pontic.

RESULTS

The failure location for the monolithic FPD was always located at the distal connector. Connector size played a key role in determining the long-term survival of the prosthesis. The fatigue resistance was predicted to be 670 N for the ZC with a connector size 4 × 3 mm, while it was only 226 N for LD. As for porcelain-fused-to-metal (PFM), FEA predicts that fatigue resistance can reach up to 770 N. Under the cyclic load of 670 N, the fatigue life for the zirconia FPD with connector size 4 × 3 mm was 2.23 × 10⁶ cycles while it survived only 3.1 × 10⁵ cycles when the connector was reduced to 3.5 × 2.5 mm. The angle of the oblique load has a significant effect on the stress distribution.

CONCLUSION

3-unit monolithic FPDs made of ZC have superior fatigue performance compared to those made of LD. The fatigue life of the zirconia FPD was about three times longer than that made of LD with a connector size of 4 mm × 3 mm. The survival rates of ZC FPDs are comparable to porcelain-fused-to-metal. A significant reduction in fatigue strength is predicted for reduced connector size. Therefore, it is necessary to establish general guidelines for the minimum connector size.

Modeling tooth enamel in FEA comparisons of skulls: Comparing common simplifications with biologically realistic models

Palaeontologists often use finite element analyses, in which forces propagate through objects with specific material properties, to investigate feeding biomechanics. Teeth are usually modeled with uniform properties (all bone or all enamel). In reality, most teeth are composed of pulp, dentine, and enamel. We tested how simplified teeth compare to more realistic models using mandible models of three reptiles. For each, we created models representing enamel thicknesses found in extant taxa, as well as simplified models (bone, dentine or enamel). Our results suggest that general comparisons of stress distribution among distantly related taxa do not require representation of dental tissues, as there was no noticeable effect on heatmap representations of stress. However, we find that representation of dental tissues impacts bite force estimates, although magnitude of these effects may differ depending on constraints. Thus, as others have shown, the detail necessary in a biomechanical model relates to the questions being examined.

Dentistry 4.0 Concept in the Design and Manufacturing of Prosthetic Dental Restorations

The paper is a comprehensive but compact review of the literature on the state of illnesses of the human stomatognathic system, related consequences in the form of dental deficiencies, and the resulting need for prosthetic treatment. Types of prosthetic restorations, including implants, as well as new classes of implantable devices called implant-scaffolds with a porous part integrated with a solid core, as well as biological engineering materials with the use of living cells, have been characterized. A review of works on current trends in the technical development of dental prosthetics aiding, called Dentistry 4.0, analogous to the concept of the highest stage of Industry 4.0 of the industrial revolution, has been presented. Authors’ own augmented holistic model of Industry 4.0 has been developed and presented. The studies on the significance of cone-beam computed tomography (CBCT) in planning prosthetic treatment, as well as in the design and manufacture of prosthetic restorations, have been described. The presented and fully digital approach is a radical turnaround in both clinical procedures and the technologies of implant preparation using computer-aided design and manufacturing methods (CAD/CAM) and additive manufacturing (AM) technologies, including selective laser sintering (SLS). The authors’ research illustrates the practical application of the Dentistry 4.0 approach for several types of prosthetic restorations. The development process of the modern approach is being observed all over the world. The use of the principles of the augmented holistic model of Industry 4.0 in advanced dental engineering indicates a change in the traditional relationship between a dentist and a dental engineer. The overall conclusion demonstrates that it is inevitable and extremely beneficial to implement the idea of Dentistry 4.0 following the assumptions of the authors’ own, holistic Industry 4.0 model.

The effect of rotation upon dental structure components following orthodontic fix appliance

Background and aims

The purpose of the study is to evaluate through a FEM (Finite Element Method) the effects of the rotation movement upon a complex structure (enamel- pulp -alveolar bone, PDL), for external load.

Method

The progressive action of a fixed orthodontic device on three teeth: first molar, first and second premolar is modeled and simulated with the components placed on the buccal and palatal surfaces of the tooth. For the reproduction of a situation similar to the real one, the loading of the model was performed through a nodal force applied at a height of the crown, of various amplitudes, F = 1 N; 2, 3 and 4 N. The values of stress are: maximum stress of the whole structure and the shearing effect for the pulp.

Results

The characteristics of the material are Young's E modulus and Poisson's ratio of the components of the modeled structure. The most stressed elements of the structure are the pulp and the ligament, revealed by von Mises stress. The elements of the structure are mainly stressed in fiber compression in the direction of the moment's action given by the orthodontic forces and in fiber stretching in the opposite direction. Out of the orthodontic movements: translation, tipping, intrusion-extrusion, rotation is the most dangerous.

Conclusions

The accumulated stress effect in the pulp becomes dangerous. The orthodontic movements given by dental force values higher than 1.5-2N are to be avoided.

Prevalence of non-carious cervical lesions among the general population of the Republic of Srpska, Bosnia and Herzegovina

INTRODUCTION

As non-carious cervical lesions (NCCLs) may compromise aesthetics and function, knowledge of their aetiological covariables enhances management of clinical complaints and success of restorative treatments.

AIMS

The primary aim of this study was to assess the presence of NCCLs among the general population of the Republic of Srpska, Bosnia and Herzegovina and the potential association with patient-related risk factors.

METHODS

A prevalence study of NCCLs included 738 respondents from eight towns/municipalities. Two dental practitioners examined all respondents. NCCLs were diagnosed according to the Smith and Knight tooth wear index, measured using a Williams periodontal probe. Data regarding risk factors were obtained through a structured questionnaire. Multivariate logistic regression was used to analyse the association of risk factors and the occurrence of NCCLs.

RESULTS

Non-carious cervical lesions were diagnosed in 384 (52%) respondents. Multivariate regression analysis showed that several variables were independently associated with the risk of developing NCCLs, including frequent consumption of acid food (P = 0.001), frequent consumption of acid drinks (P = 0.001), retaining drink in the mouth (P = 0.001), alcohol consumption (P = 0.030), bruxism (P = 0.018) and gastro-oesophageal reflux (P = 0.023). First mandibular premolars were the most affected teeth (left: 46.0%; right: 44.0%), followed by the second right maxillary premolars (37.3%), second left maxillary premolars (33.6%) and finally by the first right maxillary premolars (34.0%).

CONCLUSION

The results of the current study suggest that NCCLs occur frequently and have a multifactorial aetiology. The lowest prevalence was recorded among individuals younger than 20 years of age. As the majority of risk factors are modifiable, regular dental care could lead to the early detection of NCCLs.

The Role of Occlusal Factors in the Presence of Noncarious Cervical Lesions in Young People: A Case-Control Study

Objective:

The aim of this retrospective case-control study was to evaluate the influence of different occlusal characteristics and self-referred bruxism in the presence of noncarious cervical lesions (NCCLs).

Methods and Materials:

The participants were 280 students (140 cases and 140 controls), with an average age of 24.5 years, from six schools of dentistry in Spain. Clinical examination was carried out to record the NCCLs and the static and dynamic occlusal characteristics. The side of mastication and bruxism was collected by questionnaire. Data variables were analyzed by means of univariate and multivariate logistic regression. Odds ratios and the respective 95% confidence intervals were calculated (p<0.05).

Results:

The presence of NCCLs was significantly more likely in subjects with protrusive interferences (odds ratio [OR]=1.82); with lateral interferences, especially on the nonworking side (OR= 1.77); or who were self-reported bruxists (OR=1.72). In the multivariate analysis, protrusive interferences, bruxism, age, and the presence of attrition were risk factors for the development of NCCLs. These factors resulted in a model with an area under the receiver-operating characteristic curve of 0.667 and a positive predictive value of 61.43%.

Conclusions:

There was no significant relationship between most occlusal factors and the presence of NCCLs. Only bruxism, protrusive interferences, age, and occlusal wear were risk factors. The predictive model was not sufficiently explanatory. Occlusal factors alone do not appear to be sufficient to explain the presence of NCCLs.

Effects of non-carious cervical lesion size, occlusal loading and restoration on biomechanical behaviour of premolar teeth

BACKGROUND

Information on fracture biomechanics has implications in materials research and clinical practice. The aim of this study was to analyse the influence of non-carious cervical lesion (NCCL) size, restorative status and direction of occlusal loading on the biomechanical behaviour of mandibular premolars, using finite element analysis (FEA), strain gauge tests and fracture resistance tests.

METHODS

Ten buccal cusps were loaded on the outer and inner slopes to calculate the strain generated cervically. Data were collected for healthy teeth at baseline and progressively at three lesion depths (0.5 mm, 1.0 mm and 1.5 mm), followed by restoration with resin composite. The magnitude and distribution of von Mises stress and maximum principal stress were simulated at all stages using FEA, and fracture strength was also determined (n = 7 per group).

RESULTS

There were significant effects of the lesion size and loading directions on stress, strain and fracture resistance (p < 0.05). Fracture resistance values decreased with increase in lesion size, but returned to baseline with restorations.

CONCLUSIONS

Combined assessment of computer-based and experimental techniques provide an holistic approach to characterize the biomechanical behaviour of teeth with both unrestored and restored NCCLs.

Microbiological characterization and effect of resin composites in cervical lesions

BACKGROUND

Non carious cervical lesions associated to muscle hyperfunctions are increasing. Microhybrid resin composites are used to restore cervical abfractions. The purpose of this study was to investigate if resin composites modify tooth plaque, inducing an increment of cariogenic microflora and evaluate their effect, in vivo and in vitro, against S. mutans.

MATERIAL AND METHODS

Eight abfractions were restored with two microhybrid resin composites (Venus, Heraeus-Kulzer® and Esthet-X, Dentsply®), after gnatological therapy, in three patients with muscle hyperfunctions. For each abfraction three samples of plaque were taken from the cervical perimeter: before the restoration, one week and three months after restoration. The samples were evaluated both by traditional microbiological methods and by Polymerase Chain Reaction (PCR). In vitro, disk-shaped specimens of the two composites were prepared to estimate the effects against pre-cultured S. mutans, after incubation at 37°C for 24h and assessed by a turbidimetric technique.

RESULTS

In vivo no differences were found in plaque growth, for all samples, before and after restoration with both composites; in vitro, instead, a significant reduction of S. mutans growth was found between specimens of two composites (Mann-Whitney U-test p>0,06).

CONCLUSIONS

In this study a relevant consideration was elicited: composite materials, in vivo, do not modify plaque composition of non carious cervical lesions to a potential cariogenic plaque. Key words:Abfraction, restoration, S. mutans, composite, class V.

Biomechanics of cervical tooth region and noncarious cervical lesions of different morphology; three-dimensional finite element analysis

OBJECTIVE

The present study aims to investigate the influence of presence and shape of cervical lesions on biomechanical behavior of mandibular first premolar, subjected to two types of occlusal loading using three-dimensional (3D) finite element method (FEM).

MATERIALS AND METHODS

3D models of the mandibular premolar are created from a micro computed tomography X-ray image: model of sound mandibular premolar, model with the wedge-shaped cervical lesion (V lesion), and model with saucer-shaped cervical lesion (U lesion). By FEM, straining of the tooth tissues under functional and nonfunctional occlusal loading of 200 (N) is analyzed. For the analysis, the following software was used: CTAn program 1.10 and ANSYS Workbench (version 14.0). The results are presented in von Mises stress.

RESULTS

Values of calculated stress in all tooth structures are higher under nonfunctional occlusal loading, while the functional loading is resulted in homogeneous stress distribution. Nonfunctional load in the cervical area of sound tooth model as well as in the sub-superficial layer of the enamel resulted with a significant stress (over 50 [MPa]). The highest stress concentration on models with lesions is noticed on the apex of the V-shaped lesion, while stress in saucer U lesion is significantly lower and distributed over wider area.

CONCLUSION

The type of the occlusal teeth loading has the biggest influence on cervical stress intensity. Geometric shape of the existing lesion is very important in the distribution of internal stress. Compared to the U-shaped lesions, V-shaped lesions show significantly higher stress concentrations under load. Exposure to stress would lead to its progression.

Analysis of the abfraction lesions formation mechanism by the finite element method

Introduction:

An abfraction lesion is a type of a non-carious cervical lesion (NCCL) that represents a sharp defect on the cervical part of tooth, caused by occlusal biomechanical forces. The largest prevalence of the NCCL is found on the mandibular first premolar. The goal of the study is, by means of a numerical method – the finite element method (FEM), in an appropriate computer program, conduct a stress analysis of the mandibular premolar under various static loads, with a special reference to the biomechanics of cervical tooth region.

Material and methods:

A three-dimensional model of the mandibular premolar is gained from a µCT x-ray image. By using the FEM, straining of the enamel, dentin, peridontal ligament and alveolar bone under axial and paraxial forces of 200 [N] is analyzed. The following software were used in the analysis: CT images processing–CTAn program and FEM analysis–AnsysWorkbench 14.0.

Results:

According to results obtained through the FEM method, the calculated stress is higher with eccentric forces within all tested tooth tissue. The occlusal load leads to a significant stress in the cervical tooth area, especially in the sub-superficial layer of the enamel (over 50 MPa). The measured stress in the peridontal ligament is approximately three times higher under paraxial load with regard to the axial load, while stress calculated in the alveolar bone under paraxial load is almost ten times higher with regard to the axial load. The highest stress values were calculated in the cervical part of the alveoli, where bone resorption is most commonly seen.

Conclusion:

Action of occlusal forces, especially paraxial ones, leads to significant stress in the cervical part of tooth. The stress values in the cervical sub-superficial enamel layer are almost 5 times higher in relation to the superficial enamel, which additionally confirms complexity of biomechanical processes in the creation of abfraction lesions.

Stress analysis of occlusal forces in canine teeth and their role in the development of non-carious cervical lesions: abfraction

Non-carious cervical tooth lesions for many decades were attributed to the effects of abrasion and erosion mainly through toothbrush trauma, abrasive toothpaste, and erosive acids. However, though the above may be involved, more recently a biomechanical theory for the formation of these lesions has arisen, and the term abfraction was coined. The aim of this study was to investigate the biomechanics of abfraction lesions in upper canine teeth under axial and lateral loading conditions using a three-dimensional finite element analysis. An extracted human upper canine tooth was scanned by μCT machine (Skyscan, Belgium). These μCT scans were segmented, reconstructed, and meshed using ScanIP (Simpleware, Exeter, UK) to create a three-dimensional finite element model. A 100 N load was applied axially at the incisal edge and laterally at 45° midpalatally to the long axis of the canine tooth. Separately, 200 N axial and non-axial loads were applied simultaneously to the tooth. It was found that stresses were concentrated at the CEJ in all scenarios. Lateral loading produced maximum stresses greater than axial loading, and pulp tissues, however, experienced minimum levels of stresses. This study has contributed towards the understanding of the aetiology of non-carious cervical lesions which is a key in their clinical management.

Noncarious Cervical Lesions and Their Association With Toothbrushing Practices: In Vivo Evaluation

Knowledge of the characteristics and etiologies of noncarious cervical lesions assists dentists in selecting an appropriate treatment and improving the prognosis.

Cervical wear and occlusal wear from a periodontal perspective

The aim of this study was to investigate whether cervical wear was associated with occlusal wear and clinical periodontal parameters in relatively older adults. A total of 30 patients, with multiple non-carious cervical lesions (NCCLs) and without a disease or condition that could cause heavy tooth wear, were included in the study. The periodontal parameters including plaque index, probing pocket depth, gingival recession (GR) and tooth mobility were obtained from 641 teeth of which 475 (74·1%) displayed NCCLs. The levels of cervical wear and occlusal wear were determined according to a tooth wear index. Premolars were more likely to develop cervical wear than canines, molars and incisors. Cervical wear was significantly associated with less plaque accumulation and the presence of shallow pockets. The teeth with advanced GR and without increased mobility were 2·583 and 1·715 times more likely to develop deeper cervical lesions, respectively. Age and the level of occlusal wear were not linked to the bucco-lingual depth of cervical wear. In conclusion, the significant association of advanced cervical wear with the relatively healthy periodontal status suggested the role of abrasion and its possible combined action with erosion in the aetiology of NCCLs. The rate of GR and the lack of tooth mobility could constitute predisposing factors for the progression of cervical wear because the exposed root surfaces could be more susceptible to abrasion and/or erosion, and the non-mobile teeth resisting strongly against frictional forces, thus abrasive effects, could possibly develop cervical wear.

Modeling the effects of cingula structure on strain patterns and potential fracture in tooth enamel

The mammalian cingulum is a shelf of enamel, which rings the base of the molar crown (fully or partially). Certain nonmammalian cynodonts show precursors of this structure, indicating that it may be an important dental character in the origins of mammals. However, there is little consensus as to what drove the initial evolution of the cingulum. Recent work on physical modeling of fracture mechanics has shown that structures which approximate mammalian dentition (hard enamel shell surrounding a softer/tougher dentine interior) undergo specific fracture patterns dependent on the material properties of the food items. Soft materials result in fractures occurring at the base of the stiff shell away from the contact point due to heightened tensile strains. These tensile strains occur around the margin in the region where cingula develop. In this article, we test whether the presence of a cingulum structure will reduce the tensile strains seen in enamel using basic finite element models of bilayered cones. Finite element models of generic cone shaped "teeth" were created both with and without cingula of various shapes and sizes. Various forces were applied to the models to examine the relative magnitudes and directions of average maximum principal strain in the enamel. The addition of a cingulum greatly reduces tensile strains in the enamel caused by "soft-food" forces. The relative shape and size of the cingulum has a strong effect on strain magnitudes as well. Scaling issues between shapes are explored and show that the effectiveness of a given cingulum to reducing tensile strains is dependent on how the cingulum is created. Partial cingula, which only surround a portion of the tooth, are shown to be especially effective at reducing strain caused by asymmetrical loads, and shed new light on the potential early function and evolution of mammalian dentitions.

A 13-year clinical evaluation of two three-step etch-and-rinse adhesives in non-carious class-V lesions

This 13-year randomized clinical trial compared the clinical effectiveness of two three-step etch-and-rinse adhesives in combination with a hybrid, stiffer composite versus a micro-filled, more flexible composite. The influence of composite stiffness on the clinical performance of one of the adhesives was assessed as well. One hundred and forty-two non-carious cervical lesions were restored with composites with contrasting stiffness. Seventy-one patients randomly received two cervical restorations placed following two out of three adhesive procedures: (1) the three-step etch-and-rinse adhesive Permaquick applied with the stiff micro-hybrid composite Amelogen Hybrid (PMQ-H, Ultradent), (2) Permaquick applied with the more flexible micro-filled Amelogen Microfill (PMQ-M, Ultradent), or (3) the "gold-standard" three-step etch-and-rinse adhesive Optibond FL applied with the micro-hybrid composite Prodigy (OFL-P, Kerr). The restorations were evaluated after 6 months, 1, 2, 3, 5, 7, and 13 years of clinical service regarding their retention, marginal integrity and discoloration, caries occurrence, preservation of tooth vitality, and post-operative sensitivity. Retention loss, severe marginal defects, and/or discoloration that needed intervention (repair or replacement) and the occurrence of caries were considered as clinical failures. The recall rate at 13 years was 77%. Bond degradation after 13 years was mainly characterized by a further increase in the presence of small but clinically acceptable marginal defects and superficial marginal discoloration. Twelve percent of the OFL-P restorations were clinically unacceptable. In the PMQ group, 22% of the PMQ-M restorations and 26% of the PMQ-H restorations needed repair or replacement. Regarding the clinical failure rate, Optibond FL scored significantly better than Permaquick (McNemar; p = 0.015). No statistically significant differences were found between the micro-filled and the hybrid composite for each of the parameters evaluated (McNemar, p > 0.05). After 13 years of clinical functioning, the clinical effectiveness of the three adhesive/composite combinations remained highly acceptable.

Finite element analysis of stress concentration in Class V restorations of four groups of restorative materials in mandibular premolar

Aim:

To study the concentration of stress in class V restoration of four different restorative materials subjected to occlusal load of 100N, 150N, 200N, 250N and to analyse the obtained data with the listed properties of the restorative material.

Materials and Methods:

Using FEM analysis the stresses generated in a class V lesion in a mandibular premolar was studied.

Results:

Within the framework of the aforementioned views, and from the results of the study it can be concluded that microfilled composite is the most suitable restorative material followed by flowable composite, glass ionomer cement and resin modified glass ionomer cement.

Conclusion:

Restoration of Class V lesions with materials of higher modulus of elasticity will enable better stress distribution.

Three-dimensional stress distribution in the human periodontal ligament in masticatory, parafunctional, and trauma loads: finite element analysis

BACKGROUND

The presence of the periodontal ligament (PDL) makes it possible to absorb and distribute loads produced during masticatory function and other tooth contacts into the alveolar process via the alveolar bone proper. However, several factors affect the integrity of periodontal structures causing the destruction of the connective matrix and cells, the loss of fibrous attachment, and the resorption of alveolar bone.

METHODS

The purpose of this study was to evaluate the stress distribution by finite element analysis in a PDL in three-dimensional models of the upper central incisor under three different load conditions: 100 N occlusal loading at 45 degrees (model 1: masticatory load); 500 N at the incisal edge at 45 degrees (model 2: parafunctional habit); and 800 N at the buccal surface at 90 degrees (model 3: trauma case). The models were built from computed tomography scans.

RESULTS

The stress distribution was quite different among the models. The most significant values (harmful) of tensile and compressive stresses were observed in models 2 and 3, with similarly distinct patterns of stress distributions along the PDL. Tensile stresses were observed along the internal and external aspects of the PDL, mostly at the cervical and middle thirds.

CONCLUSIONS

The stress generation in these models may affect the integrity of periodontal structures. A better understanding of the biomechanical behavior of the PDL under physiologic and traumatic loading conditions might enhance the understanding of the biologic reaction of the PDL in health and disease.

All-ceramic and porcelain-fused-to-metal fixed partial dentures: a comparative study by 2D finite element analyses

All-ceramic fixed partial dentures (FPDs) have an esthetic approach for oral rehabilitation. However, metal-ceramic FPDs are best indicated in the posterior area where the follow-up studies found a lower failure rate. This 2D finite element study compared the stress distribution on 3-unit all-ceramic and metal-ceramic FPDs and identified the areas of major risk of failure. Three FPD models were designed: (1) metal-ceramic FPD; (2) All-ceramic FPD with the veneering porcelain on the occlusal and cervical surface of the abutment tooth; (3) All-ceramic FPD with the veneering porcelain only on the occlusal surface. A 100 N load was applied in an area of 0.5 mm² on the working cusps, following these simulations: (1) on the abutment teeth and the pontic; (2) only on the abutment teeth; and (3) only on the pontic. Relative to the maximum stress values found for the physiological load, all-ceramic FPD with only occlusal veneering porcelain produced the lowest stress value (220 MPa), followed by all-ceramic FPD with cervical veneering porcelain (322 MPa) and metal-ceramic FPD (387 MPa). The stress distribution of the load applied on the abutments was significantly better compared to the other two load simulations. The highest principal stress values were low and limited in a small area for the three types of models under this load. When the load was applied on the pontic, the highest stress values appeared on the connector areas between the abutments and pontic. In conclusion, the best stress values and distribution were found for the all-ceramic FPD with the veneering porcelain only on the occlusal surface. However, in under clinical conditions, fatigue conditions and restoration defects must be considered.

Non-carious cervical tooth surface loss: a literature review

OBJECTIVES

As the population ages and teeth are increasingly retained for life the incidence of non-carious cervical tooth surface loss is increasing but little is understood about the aetiology and management of these lesions. The purpose of this literature review was to review and critically appraise the literature as it relates to the prevalence, aetiology and treatment of non-carious cervical tooth surface loss.

SEARCH STRATEGY

An electronic search, using OVID electronic bibliographic databases was performed with no restriction on the language of publication.

CONCLUSIONS

Despite the paucity of research into non-carious cervical tooth surface loss it was concluded that the number and size of lesions increases with age, lesions are more common on the facial aspects of teeth and the formation of lesions appears to be multi-factorial with lesion shape not being a predictor of aetiology. It was also concluded that the value of restoring these lesions, where indicated, is unclear and that occlusal adjustment to increase the retention of restorations placed to restore lesions or to halt lesion progression cannot be supported.

Bone stress and interfacial sliding analysis of implant designs on an immediately loaded maxillary implant: a non-linear finite element study

OBJECTIVES

This study investigated the surrounding bone stress and the implant-bone interfacial sliding of implant designs and implant sizes of immediately loaded implant with maxillary sinus augmentation by using three-dimensional (3D) non-linear finite element (FE) analysis.

METHODS

Twenty-four FE models including four implant designs (cylindrical, threaded, stepped and step-thread implants) and three implant dimensions (standard, long and wide threaded implants) with a bonded and three levels of frictional contact of implant-bone interfaces were analyzed. The maxillary model was constructed from computer tomography (CT) images of a human skull and all 3D implant models were created via the computer-aided design (CAD) software.

RESULTS

The use of threaded implants decreased the bone stress and sliding distance obviously about 30% as compared with non-threaded (cylindrical and stepped) implants. Increasing the implant's length or diameter reduced the bone stress by 13-26%. Employing a immediately loaded implant with smooth machine surface (mu=0.3, mu represents frictional coefficient) increased the bone stress by 28-63% as compared with the osseointegrated (bonded interfaces) implants. Roughening the implant surface (mu>0.3) did not reduced the bone stress, however it did decrease the interfacial sliding between implant and bone.

CONCLUSIONS

For an immediately loaded implant placed with sinus augmentation, using threaded implant could decrease both the bone stress and implant-bone sliding distance which may improve the implant initial stability and long-term survival. Rough surface of implants shows no benefit to reduce the bone stress but they could lower the interfacial sliding. On the contrary, employing long or wide implants decrease the bone stress but they cannot diminish the interfacial sliding.

Incidence of noncarious cervical lesions and their relation to the presence of wear facets

PROBLEM

Noncarious cervical lesions are characterized by loss of tooth structure in the cervical area, compromising its integrity and resulting in esthetic problems for the patient.

PURPOSE

The purpose of this study was to assess noncarious cervical lesions in young patients in an attempt to establish a possible relationship to the presence of wear facets.

MATERIALS AND METHODS

First-year dental students of Bauru Dental School were studied to verify the prevalence of noncarious cervical lesions and their relationship to the presence of wear facets. After 3 years, the students were examined again to verify the incidence of new lesions, trying to establish a correlation to the previous existence of wear facets.

RESULTS

Of the 1,131 teeth analyzed, 129 had noncarious cervical lesions. Twenty-nine of the 40 students had at least one tooth with one lesion. After 3 years, the incidence of new lesions was 57. Mandibular first molars (22.3%), mandibular first premolars (13.2%), mandibular second premolars (13.2%), and maxillary first molars (12.4%) showed the highest prevalence of lesions. On final analysis, 86.8% of all teeth presenting lesions showed wear facets. The identification of new lesions associated with the presence of wear facets identified during the first exam 3 years earlier was statistically significant (p < 0.01).

CONCLUSIONS

The patterns of wear facets found in the study population examined were associated with an increased occurrence of noncarious cervical lesions.

CLINICAL SIGNIFICANCE

Occlusal factors, especially the presence of wear facets, should be considered in the management of noncarious cervical lesions.

In vivo evaluation of noncarious cervical lesions in sleep bruxism subjects

STATEMENT OF PROBLEM

Occlusal load has frequently been suggested to be involved in the development of a noncarious cervical lesion (NCL). However, there is a lack of clinical studies evaluating NCLs and occlusal parameters in sleep bruxism (SB) subjects.

PURPOSE

The purpose of this clinical study was to assess the frequency of NCLs and determine potential occlusal differences between SB subjects and healthy control subjects.

MATERIAL AND METHODS

A total of 91 volunteers, 58 women and 33 men, with a mean (SD) age of 28.37 (4.89) years (range of 20 to 39 years), participated in this investigation. The clinical assessment of SB was based on the criteria of the American Academy of Sleep Medicine. The participants were divided into 2 groups; 58 subjects were assigned to the SB group and 33 subjects to the control group, following a thorough dental examination that was performed by a single trained dentist. Additionally, the following parameters were recorded: mean number of teeth present, existence/absence of NCLs, frequency of NCLs relating to the type of tooth, type of occlusal guidance scheme, existence of a slide from centric occlusion (CO) to maximum intercuspation (MI), length of the slide, and report of tooth hypersensitivity. Group differences were statistically analyzed using chi-square tests for the qualitative variables and Mann-Whitney U tests for the quantitative variables (alpha=.05).

RESULTS

NCLs were significantly more prevalent in SB subjects (39.7%) than in the control subjects (12.1%) (P=.006). In SB subjects, the first premolars were the teeth most affected, and in control subjects, the first molars were most affected. Tooth hypersensitivity was reported in 62.1% of the SB subjects and in 36.4% of the control subjects (P=.018). The evaluation of occlusal guidance schemes revealed no significant difference between the groups. In SB subjects (70.7%), a slide from CO to MI was significantly more prevalent than in control subjects (42.4%) (P=.008). Moreover, SB subjects demonstrated a significantly longer mean (SD) slide of 0.77 (0.69) mm compared to that of control subjects of 0.4 (0.57) mm (P=.008).

CONCLUSIONS

Within the limitations of this study, SB subjects demonstrated significantly more NCLs than the control group; whereas, the type of occlusal guidance scheme seems to be of minor importance in the development of NCLs.

Mechanical evaluation of cervical glass-ionomer restorations: 3D finite element study

OBJECTIVES

The aim of this paper was to investigate the influence of lesion shape and depth as well as the direction of occlusal loading on the mechanical response of cervical GIC restorations.

METHODS

A finite element model of a lower first premolar was created. Both wedged and rounded lesions were then modelled with incremental depth after which the tooth was loaded at different angles. First principal stress (tension) was employed as an indicator of material failure, by contrasting our calculated stresses with the ultimate tensile strength of the GIC and known values of bond strength between material and tooth substrate.

RESULTS

Obliquely loaded teeth exhibited significantly higher tensile stress in the cervical region of the restoration. For forces inclined at angles of 30 degrees and higher to the vertical tooth axis, the tensile stresses in the cervical margin of the restoration exceeded the ultimate material and bond strength. In contrast, lesion shape and depth have only a minor influence on tensile stress development.

CONCLUSIONS

Lesion depth and shape are not of primary concern from a mechanical perspective for a restorative treatment decision. By contrast, occlusal diagnosis and subsequent re-adjustments of tooth contacts do form a critical part of the treatment of non-carious cervical lesions (NCCLs).

A critical review of non-carious cervical (wear) lesions and the role of abfraction, erosion, and abrasion

The terms 'abfraction' and 'abrasion' describe the cause of lesions found along the cervical margins of teeth. Erosion, abrasion, and attrition have all been associated with their formation. Early research suggested that the cause of the V-shaped lesion was excessive horizontal toothbrushing. Abfraction is another possible etiology and involves occlusal stress, producing cervical cracks that predispose the surface to erosion and abrasion. This article critically reviews the literature on abrasion, erosion, and abrasion, and abfraction. The references were obtained by a MEDLINE search in March, 2005, and from this, hand searches were undertaken. From the literature, there is little evidence, apart from laboratory studies, to indicate that abfraction exists other than as a hypothetical component of cervical wear.

The biomechanics of abfraction

The role of occlusal loading in the development of non-carious cervical lesions is becoming increasingly prominent. It is suggested that high occlusal loads result in large stress concentrations in the cervical region of the teeth. These stresses may be high enough to cause disruption of the bonds between the hydroxyapatite crystals, eventually resulting in the loss of cervical enamel.

This article reviews the evidence to support the thesis that occlusal loading can contribute to the process of non-carious cervical tooth loss or abfraction. It also reviews the potential interactions between occlusal loading and erosion that may contribute to non-carious cervical tooth loss.

Finite element analysis of mechanism of cervical lesion formation in simulated molars during mastication and parafunction

STATEMENT OF PROBLEM

The mechanical theory of cervical lesion formation is popular; however, the mechanism of formation of these lesions is not fully explained.

PURPOSE

The aim of this study was calculation of the stresses and Tsai-Wu strength ratio in the cervical area of the mandibular molar during grinding, clenching, and mastication, as well as theoretical investigation of the mechanism of cervical lesion formation in teeth.

MATERIAL AND METHODS

A 2-dimensional finite element model of the mandibular first molar and crown of the opposing maxillary molar in the frontal section was developed. Computational simulation of mastication of a bolus with high elastic modulus, including grinding and clenching, was performed. Pairs of contact elements were used between the bolus and occlusal surfaces of the teeth. The analysis was nonlinear. During these simulations, the pressure exerted on the occlusal surface and the state of stresses in the mandibular molar were calculated. To evaluate the strength of anisotropic tooth tissues, the Tsai-Wu failure criterion was applied. This criterion considers the difference in strength of materials due to tensile, compressive, and shear stresses.

RESULTS

Significant pressures were exerted on lingual cusps of the mandibular molar model during computer simulations of physiological and pathological load. In enamel elements close to the buccal cemento-enamel junction (CEJ) of the studied tooth, tensile stresses were observed which exceeded the strength of the enamel. In this area, the Tsai-Wu strength ratio reached values higher than 1. According to the Tsai-Wu criterion, these elements were damaged and, thus, were removed from the computer tooth model. During subsequent modeling of the tooth with the initiated cervical lesion, the Tsai-Wu ratio exceeded 1 along the dentino-enamel junction (DEJ), creating an overhang of enamel in the cervical area. Application of minimal horizontal force caused a fracture of this fragile, unsupported enamel fragment.

CONCLUSIONS

Overloading of theoretical teeth by computer simulation resulted in enamel damage at the CEJ and led to initiation of a cervical lesion. Subsequent overloading resulted in enamel destruction along the DEJ. The overhanging enamel fragment may easily be chipped. This process was repeated during subsequent tooth overloading and caused enlarging of the lesion.

Can internal stresses explain the fracture resistance of cusp-replacing composite restorations?

The aim of this study was to explore and compare the results of occlusal load application to cusp-replacing composite restorations, studied by means of finite element (FE) analysis and in vitro load tests. A three-dimensional (3D) FE model was created with a set up similar to an in vitro load test that assessed the fatigue resistance of upper premolars with buccal cusp-replacing resin composite restorations. Occlusal load was applied to two geometries (with and without palatal cuspal coverage), and the tooth-restoration interface and composite material stresses were calculated. Subsequently, safety factors were calculated by dividing the material strength values by the obtained stresses. The highest safety factors were observed for the restorations with cuspal coverage. This was consistent with the load test, in which cuspal coverage led to higher fracture resistance. Furthermore, the FE analysis predicted that failure of the tooth-restoration interface is more likely than failure of the composite material. Correspondingly, the load test showed predominantly adhesive failures of the restorations. Although the described test methods did not lead to a complete understanding of the failure mechanism, it can be concluded that the FE analysis provides additional information with regard to the differences in fracture behaviour of these types of restorations.