A data-driven approach for the partial reconstruction of individual human molar teeth using generative deep learning

Background and objective

Due to the high prevalence of dental caries, fixed dental restorations are regularly required to restore compromised teeth or replace missing teeth while retaining function and aesthetic appearance. The fabrication of dental restorations, however, remains challenging due to the complexity of the human masticatory system as well as the unique morphology of each individual dentition. Adaptation and reworking are frequently required during the insertion of fixed dental prostheses (FDPs), which increase cost and treatment time. This article proposes a data-driven approach for the partial reconstruction of occlusal surfaces based on a data set that comprises 92 3D mesh files of full dental crown restorations.

Methods

A Generative Adversarial Network (GAN) is considered for the given task in view of its ability to represent extensive data sets in an unsupervised manner with a wide variety of applications. Having demonstrated good capabilities in terms of image quality and training stability, StyleGAN-2 has been chosen as the main network for generating the occlusal surfaces. A 2D projection method is proposed in order to generate 2D representations of the provided 3D tooth data set for integration with the StyleGAN architecture. The reconstruction capabilities of the trained network are demonstrated by means of 4 common inlay types using a Bayesian Image Reconstruction method. This involves pre-processing the data in order to extract the necessary information of the tooth preparations required for the used method as well as the modification of the initial reconstruction loss.

Results

The reconstruction process yields satisfactory visual and quantitative results for all preparations with a root mean square error (RMSE) ranging from 0.02 mm to 0.18 mm. When compared against a clinical procedure for CAD inlay fabrication, the group of dentists preferred the GAN-based restorations for 3 of the total 4 inlay geometries.

Conclusions

This article shows the effectiveness of the StyleGAN architecture with a downstream optimization process for the reconstruction of 4 different inlay geometries. The independence of the reconstruction process and the initial training of the GAN enables the application of the method for arbitrary inlay geometries without time-consuming retraining of the GAN.

Generative deep learning approaches for the design of dental restorations: A narrative review

OBJECTIVES

This study aims to explore and discuss recent advancements in tooth reconstruction utilizing deep learning (DL) techniques. A review on new DL methodologies in partial and full tooth reconstruction is conducted.

DATA/SOURCES

PubMed, Google Scholar, and IEEE Xplore databases were searched for articles from 2003 to 2023.

STUDY SELECTION

The review includes 9 articles published from 2018 to 2023. The selected articles showcase novel DL approaches for tooth reconstruction, while those concentrating solely on the application or review of DL methods are excluded. The review shows that data is acquired via intraoral scans or laboratory scans of dental plaster models. Common data representations are depth maps, point clouds, and voxelized point clouds. Reconstructions focus on single teeth, using data from adjacent teeth or the entire jaw. Some articles include antagonist teeth data and features like occlusal grooves and gap distance. Primary network architectures include Generative Adversarial Networks (GANs) and Transformers. Compared to conventional digital methods, DL-based tooth reconstruction reports error rates approximately two times lower.

CONCLUSIONS

Generative DL models analyze dental datasets to reconstruct missing teeth by extracting insights into patterns and structures. Through specialized application, these models reconstruct morphologically and functionally sound dental structures, leveraging information from the existing teeth. The reported advancements facilitate the feasibility of DL-based dental crown reconstruction. Beyond GANs and Transformers with point clouds or voxels, recent studies indicate promising outcomes with diffusion-based architectures and innovative data representations like wavelets for 3D shape completion and inference problems.

CLINICAL SIGNIFICANCE

Generative network architectures employed in the analysis and reconstruction of dental structures demonstrate notable proficiency. The enhanced accuracy and efficiency of DL-based frameworks hold the potential to enhance clinical outcomes and increase patient satisfaction. The reduced reconstruction times and diminished requirement for manual intervention may lead to cost savings and improved accessibility of dental services.

Biaxial Flexural Strength of Printed Splint Materials

One therapeutical alternative in the treatment of functional disorders is the use of printed oral splints. The mechanical properties of these materials are highly essential to their clinical effectiveness, and their performance may vary depending on factors such as cleaning, post-polymerization, or their orientation during construction. The objective of this in vitro investigation is to evaluate the effectiveness of the selected materials in terms of their biaxial flexural strength in relation to the criteria listed above. Splint materials were used in the printing of 720 discs. The printing process was carried out in different orientations in relation to the building platform. Either an automatic or manual cleaning process was performed on the samples. For post-polymerization, either an LED or Xenon light was utilized. A piston-on-three-ball test was used to measure the biaxial flexural strength (BFS) of the materials after they were stored in water for either 24 h or 60 days. The homogeneity of the data was controlled by employing the Levene method, and the differences between the groups were analyzed using the ANOVA and Bonferroni methods. After being stored for twenty-four hours, the mean BFS ranged anywhere from 79 MPa to 157 MPa. Following a period of sixty hours, the BFS exhibited a substantial drop and revealed values that ranged from 72 to 127 MPa. There was no significant difference that could be identified between the materials or between the various cleaning processes. The results of post-polymerization showed that the LED light produced higher means than the Xenon light did. In terms of position, the mean values varied greatly, with 0°'s mean value being 101 MPa, 45°'s mean value being 102 MPa, and 90°'s mean value being 115 MPa. The use of a build orientation of 90° and post-polymerization with LED light resulted in significantly increased biaxial flexural strength. According to this study, this design should be implemented in order to ensure that splint materials have the highest possible strength.

Influence of cement type, excess removal, and polishing on the cement joint

OBJECTIVES

To compare marginal gap width and depth with different cementation systems, excess removal, and after polishing.

METHOD AND MATERIALS

In total, 80 composite crowns were milled, divided into ten groups, and cemented on identical artificial teeth. Eight crowns per group were fixed with (i) zinc phosphate cement (ZnOPh), (ii) glass-ionomer cement (GIC), (iii) resin-reinforced glass-ionomer cement (GIC mod), (iv) dual-curing adhesive composite (Comp dual), or (v) dual-curing self-adhesive composite (Comp SE dual). Excess removal was performed with a scaler after brief light-cure (tack-cure), final light-cure, during rubber or gel phase or by wiping with foam pellet. Curing was completed in chemical, dark cure, or light-curing modus. The specimens were polished and stored in water (37°C). The margins were digitized using a 3D laser-scanning microscope (VK-X100 series, Keyence). The width and the depth of the marginal gap were measured at 10 points between the crown margin and the preparation margin.

RESULTS

The width after excess removal varied between 65.1 ± 15.7 µm (Comp dual, wipe, with polishing) and 208.6 ± 266.7 µm (Comp SE dual, dark cure, without polishing). The depth varied between 29.8 ± 22.2 µm (Comp dual, wipe, with polishing) and 89.5 ± 45.2 µm (Comp SE dual, dark cure, without polishing). The impact on gap width and depth was detected for fixation material, excess removal, and polishing.

CONCLUSION

The gap depth and width depend on the luting material and the mode of access removal. Polishing can improve the gap quality, especially for GIC and resin-based systems.

Comparison of surface roughness parameters Ra/Sa and Rz/Sz with different measuring devices

OBJECTIVES

The aim of this in-vitro study was to investigate the influence of the measuring devices (mechanical and optical) on the surface values Ra/Sa and Rz/Sz of different materials and machined surfaces.

MATERIAL AND METHODS

Mechanical (contact profilometry (CP): Perthometer S6P, Perthen Mahr, G) and optical (scanning electron microscope (SEM): Phenom, FEI, NL; confocal 3D laser scanning microscope (CLSM): VK-100, Keyence, J) measuring devices were used to determine the surface roughness Ra/Sa and Rz/Sz. Glass-ceramic (Empress, Ivoclar-Vivadent, FL), zirconia (Cercon HT, Dentsply, D), composite (Grandio, Voco, D), denture base material (Palapress, Kulzer, D) and titanium (grade 4) were investigated (n = 10 measurements) after surface finishing: sandblasting (Al2O3; 250 μm), diamond treatment (80 μm; wet), sandblasting (Al2O3; 50 μm), and polishing (grit of 4000; wet; Tegramin-25, Struers, D).

STATISTICS

Shapiro-Wilk, ANOVA, Bonferroni post-hoc tests (α = 0.05).

RESULTS

Surface characteristics Ra/Sa and Rz/Sz, which were detected with mechanical and optical measuring devices on different materials and surface finishing, showed significant (p ≤ 0.001, ANOVA) differences. Significant (p ≤ 0.045, Bonferroni) differences between CP, SEM and CLSM (line; area) were found, mainly for Ra/Sa.

DISCUSSION

The surface roughness on different dental materials and differently machined surfaces were influenced by the individual mechanical and optical measuring devices. Optical methods measure a significantly higher roughness value for all materials and surface finishes.

Effects of storage and toothbrush simulation on Martens hardness of CAD/CAM, hand-cast, thermoforming, and 3D-printed splint materials

OBJECTIVES

To investigate Martens hardness parameters of splint materials after storage in liquids and toothbrush simulation.

MATERIALS AND METHODS

Ten specimens per material and group were fabricated (hand-cast CAST, thermoformed TF, CAD/CAM-milled CAM, 3D-printed PS, PL, PK, PV), stored in air, water, coffee, red wine, and cleaning tablets and investigated after fabrication, 24 h, 2- and 4-week storage or toothbrushing. Martens hardness (HM), indentation hardness (HIT), indentation modulus (EIT), the elastic part of indentation work (ηIT), and indentation creep (CIT) were calculated (ISO 14577-1).

STATISTICS

ANOVA, Bonferroni post hoc test, between-subjects effects, Pearson correlation (α = 0.05).

RESULTS

HM varied between 30.8 N/mm2 for PS (water 4 weeks) and 164.0 N/mm2 for CAM (toothbrush). HIT values between 34.9 N/mm2 for PS (water 4 weeks) and 238.9 N/mm2 for CAM (toothbrush) were found. EIT varied between 4.3 kN/mm2 for CAM (toothbrush) and 1.8 kN/mm2 for PK (water 2 weeks). ηIT was found to vary between 16.9% for PS (water 4 weeks) and 42.8% for PL (toothbrush). CIT varied between 2.5% for PL (toothbrush) and 11.4% for PS (water 4 weeks). The highest impact was identified for the material (p ≤ 0.001).

CONCLUSIONS

Storage and toothbrushing influenced Martens parameters. The properties of splints can be influenced by the choice of materials, based on different elastic and viscoelastic parameters. High HM and EIT and low CIT might be beneficial for splint applications.

CLINICAL RELEVANCE

Martens parameters HM, EIT, and CIT might help to evaluate clinically relevant splint properties such as hardness, elasticity, and creep.

Influence of fabrication settings on the in-vitro performance of subtractively manufactured resin-based molar crowns

PURPOSE

To investigate the influence of milling parameters on the durability during in-vitro aging-simulation, and fracture force of resin-based composite crowns.

MATERIALS AND METHODS

Identical molar crowns (n=8 per group) were milled from resin-based composite crowns (Grandio, VOCO, Germany) with different processing speed (soft, normal, fast) or level of details (very high, high, low) form 98mm discs. To investigate the influence of cooling, one group was milled wet. The influence of polishing was tested in two groups. All crowns were adhesively bonded on standardized resin-based composite molars. Aging was performed with thermal cycling and mechanical loading (2x3000x5°C/55°C, 2min, H20 dist., 1.2x106 force 50N). Fracture forces were determined (v=1mm/min, Z010, Zwick, Germany).

STATISTICS

Pearson-correlation, one-way ANOVA, Bonferroni post-hoc-tests (α=0.05).

RESULTS

All crowns survived TCML without any failures. The fracture values varied between 1237.3 ± 326.7N and 3308.6 ± 655.8N. Significant (p<0.001) differences between the individual manufacturing approaches were detected. Failure was categorized as a fracture of the crown and partial loosening of the crown. No different failure pattern was observed between the tested systems.

CONCLUSION

A medium level of detail seems to be ideal to achieve highest fracture forces. No relationship existed between machining speed and fracture force. Fracture force was not affected by wet grinding. In individual cases, polishing reduced crown fracture values, due to reduced wall thickness.

Aging and Fracture Resistance of Implant-Supported Molar Crowns with a CAD/CAM Resin Composite Veneer Structure

Chipping of implant-supported molar crowns (iSCs) is a frequently reported complication. This study aimed to investigate the in-vitro aging and fracture resistance of iSCs with a CAD/CAM resin composite veneer structure fabricated with the Rapid Layer Technology (RLT) approach. Eight iSCs per group were fabricated by using two different CAD/CAM resin composites (Shofu Block HC: SH; Grandio blocs: GB) for veneer structures, and zirconia (ZrO2), polyetheretherketone (PEEK), and cobalt-chromium (CoCr; control) as framework materials. The surfaces to be bonded were sandblasted, cleaned in an ultrasonic bath, and a coupling agent was applied. A self-adhesive resin luting composite was used to adhesively lute the veneer structures to the frameworks. The crowns were semi-permanently cemented to the abutments. After storage in deionized water, iSCs were loaded in a chewing simulator (TCML, 10,000 thermal cycles 5 °C to 55 °C for 20 s, 1.2 million, loading force 50 N). Four ZrO2 and one CoCr crown did not survive the TCML. The fracture force was determined after 24 h storage in deionized water and yielded values of ≥974 N. Lowest fracture forces were yielded in the PEEK-SH group in comparison to CoCr or ZrO2 groups (p ≤ 0.031). For identical framework materials, no significant influence of the veneering material was observed. All PEEK-GB frameworks fractured, and chipping occurred for ZrO2-SH and all CoCr frameworks. PEEK-SH and ZrO2-GB presented both chipping and framework fractures. Within the limitations of this in-vitro study, the RLT with a CAD/CAM resin composite veneer structure might be a promising approach to veneer iSCs. Yet, the choice of the CAD/CAM resin composite and of the framework material determine the fracture resistance.

Finite Element Analysis of Occlusal Interferences in Dental Prosthetics Caused by Occlusal Adjustment

PURPOSE

To investigate the influence of occlusal interference using finite element analysis (FEA).

MATERIALS AND METHODS

The FEA model designed for this study centered on an all-ceramic, bilayered, fixed partial denture (FPD) retained on the maxillary first premolar and first molar, with the second premolar replaced by a pontic. The surrounding structures-such as the neighboring teeth, antagonists, and periodontium-were modeled. Four different loading cases were designed at occlusal interferences of 0, 8, 12, and 24 μm and were loaded by a simulated bite force of 300 N. Principal and von Mises stresses, as well as strain, were evaluated for all included structures.

RESULTS

For interferences of 12 and 24 μm, failure-relevant tensile stresses in the veneering layer were observed at the occlusal surfaces. Stress found in the zirconia FPD did not reach fatigue or flexural strength for any test load.

CONCLUSION

Peak tensile stress was observed in close proximity to occlusal contact points, increasing with increasing occlusal interference. The FEA results suggest that the majority of occlusal stress is absorbed by the deformation of the periodontal ligament. Framework failure caused by the simulated interferences was not expected. Surface defects may ultimately lead to failure due to fracture or chipping, especially in cases of weaker ceramics or veneering.

In vitro fatigue and fracture testing of temporary materials from different manufacturing processes in implant-supported anterior crowns

OBJECTIVES

The aim of this study was to investigate the in vitro fatigue and fracture force of temporary implant-supported anterior crowns made of different materials with different abutment total occlusal convergence (TOC), with/without a screw channel, and with different types of fabrication.

MATERIALS AND METHODS

One hundred ninety-two implant-supported crowns were manufactured (4° or 8° TOC; with/without screw channel) form 6 materials (n = 8; 2 × additive, 3 × subtractive, 1 × automix; reference). Crowns were temporarily cemented, screw channels were closed (polytetrafluoroethylene, resin composite), and crowns were stored in water (37 °C; 10 days) before thermal cycling and mechanical loading (TCML). Fracture force was determined.

STATISTICS

Kolmogorov-Smirnov, ANOVA; Bonferroni; Kaplan-Meier; log-rank; α = 0.05.

RESULTS

Failure during TCML varied between 0 failures and total failure. Mean survival was between 1.8 × 105 and 4.8 × 105 cycles. The highest impact on survival presented the material (η2 = 0.072, p < .001). Fracture forces varied between 265.7 and 628.6 N. The highest impact on force was found for the material (η2 = 0.084, p < .001).

CONCLUSION

Additively and subtractively manufactured crowns provided similar or higher survival rates and fracture forces compared to automix crowns. The choice of material is decisive for the survival and fracture force. The fabrication is not crucial. A smaller TOC led to higher fracture force. Manually inserted screw channels had negative effects on fatigue testing.

CLINICAL RELEVANCE

The highest stability has been shown for crowns with a low TOC, which are manufactured additively and subtractively. In automix-fabricated crowns, manually inserted screw channels have negative effects.

Effect of apical root resection, orthodontic extrusion, and surgical crown lengthening on load capability

OBJECTIVES

This study aims to investigate the load-to-fracture of procedures changing crown-to-root ratio (RCRR) aimed to restore severely damaged upper central incisors to avoid tooth extraction compared to implant placement. There is no evidence on load capability after apical root resection (AR), orthodontic extrusion (OE), and surgical crown lengthening (SCL) in respect to RCRR, respectively.

MATERIAL AND METHODS

Human maxillary central incisors were endodontically treated, decoronated, and divided into 4 groups (n = 48). The following specimen preparation was performed: (I) adhesive core-and-post build-up (control), (II) as (I) and 2 mm apical root resection (AR), (III) before adhesive core-and-post build-up teeth were shortened 2 mm coronally (OE) (IV) as (I), but specimens were embedded 4 mm instead of 2 mm below the CEJ (SCL), group (V) implant-borne restoration with individual all-ceramic abutments (n = 12; ∅4.1/l = 12 mm) (IBR). All specimens received all-ceramic crowns, thermo-mechanical (TML), and subsequent linear loading (LL) until failure. RCRR were calculated and log-rank, Kruskal-Wallis, Mann-Whitney U, ANOVA, and chi-square tests applied (p = 0.05).

RESULTS

Fracture loads after subsequent LL differed significantly (p = 0.001) between groups, while implants showed the highest values. Fmax median (min/max) were as follows: (I) 252 (204/542), (II) 293 (243/443), (III) 253 (183/371), (IV) 195 (140/274), and (V) 446 (370/539). Pair-wise comparison showed significant differences (p = 0.001) between group I/IV and group V, I, and IV (p = 0.045), II and IV (p = 0.001), and III compared to IV (p = 0.033), respectively. RCRR below 1 significantly increased load capability compared to RCRR = 1.

CONCLUSIONS

OE appears to preferably ensure biomechanical stability of teeth that are endodontically treated and receive core-and-post and crown placement compared to SCL. AR has no adverse biomechanical impact. RCRR < 1 is biomechanically beneficial.

CLINICAL RELEVANCE

For endodontically treated and restored teeth, orthodontic extrusion should be preferred compared to surgical crown lengthening prior single-crown restoration. As orthodontic extrusion, apical root resection has no adverse effect on load capability. Single-crown implant-borne restorations are most load capable.

Aging and fracture resistance of screw-retained implant-supported molar crowns fabricated from lithium disilicate containing virgilite

Purpose To investigate aging and fracture resistance of screw-retained implant-supported single crowns (iSCs) fabricated from lithium disilicate containing virgilite (VLD). Materials and Methods iSCs were fabricated from VLD (CEREC Tessera, Dentsply Sirona) and lithium disilicate (control; n=8, e.max CAD, Ivoclar) and bonded to a Ti-base abutment. VLD crowns were luted either with (VLDc, n=8) or without (VLDw, n=8) a coupling agent. iSCs were cleaned, sterilized, and screw-retained on implants. Fracture force was determined after thermal cycling and mechanical loading (TCML). Results All crowns survived TCML. No significant differences in mean fracture forces were identified between VLDc 1583 N, VLDw 1694 N, and control 1797 N (P=0.639 ANOVA, P=1.000 Bonferroni). Conclusion Screw-retained iSCs fabricated from VLD provide acceptable stability, which is independent on the usage of a coupling agent for bonding to Ti-base abutments and sterilization. Int J Prosthodont 2023. doi: 10.11607/ijp.8369.

Bacterial Adhesion on Dental Polymers as a Function of Manufacturing Techniques

The microbiological behavior of dental polymer materials is crucial to secure the clinical success of dental restorations. Here, the manufacturing process and the machining can play a decisive role. This study investigated the bacterial adhesion on dental polymers as a function of manufacturing techniques (additive/subtractive) and different polishing protocols. Specimens were made from polyaryletherketone (PEEK, PEKK, and AKP), resin-based CAD/CAM materials (composite and PMMA), and printed methacrylate (MA)-based materials. Surface roughness (R_z; R_a) was determined using a laser scanning microscope, and SFE/contact angles were measured using the sessile drop method. After salivary pellicle formation, in vitro biofilm formation was initiated by exposing the specimens to suspensions of Streptococcus mutans (S. mutans) and Streptococcus sanguinis (S. sanguinis). Adherent bacteria were quantified using a fluorometric assay. One-way ANOVA analysis found significant influences (p < 0.001) for the individual parameters (treatment and material) and their combinations for both types of bacteria. Stronger polishing led to significantly (p < 0.001) less adhesion of S. sanguinis (Pearson correlation PC = -0.240) and S. mutans (PC = -0.206). A highly significant (p = 0.010, PC = 0.135) correlation between S. sanguinis adhesion and R_z was identified. Post hoc analysis revealed significant higher bacterial adhesion for vertically printed MA specimens compared to horizontally printed specimens. Furthermore, significant higher adhesion of S. sanguinis on pressed PEEK was revealed comparing to the other manufacturing methods (milling, injection molding, and 3D printing). The milled PAEK samples showed similar bacterial adhesion. In general, the resin-based materials, composites, and PAEKs showed different bacterial adhesion. Fabrication methods were shown to play a critical role; the pressed PEEK showed the highest initial accumulations. Horizontal DLP fabrication reduced bacterial adhesion. Roughness < 10 µm or polishing appear to be essential for reducing bacterial adhesion.

Microstructure, composition, and flexural strength of different layers within zirconia materials with strength gradient

OBJECTIVES

The aim of this study was to compare composition, microstructure, and mechanical strength of current multilayer zirconia blanks.

METHODS

Bar shaped specimens were made from several layers of multilayer zirconia blanks (Cercon ht ML, Dentsply Sirona, US; Katana Zirconia YML, Kuraray, J;SHOFU Disk ZR Lucent Supra, Shofu, J; priti multidisc ZrO₂ Multi Translucent, Pritidenta, D; IPS e.max ZirCAD Prime, Ivoclar Vivadent, FL). Flexural strength was determined in a three-point bending test on extra-thin bars. X-ray diffraction (XRD) with Rietveld refinement was used to assess crystal structure and scanning electron microscopy (SEM) imaging to visualize the microstructure of each material and layer.

RESULTS

Mean flexural strength varied between 467.5 ± 97.5 MPa (top layer, IPS e.max ZirCAD Prime) and 898.0 ± 188.5 MPa (bottom layer, Cercon ht ML) with significant (p ≤ 0.055) differences between the individual layers. XRD indicated 5Y-TZP for enamel-layers, 3Y-TZP for dentine-layers, individual mixtures of 3Y-TZP, 4Y-TZP, or 5 Y-TZP for intermediate layers. SEM analysis showed grain sizes between approx. 0.15 and 4 µm. Grain size tended to decrease from top to bottom layers.

SIGNIFICANCE

The investigated blanks differ predominantly in the intermediate layers. In addition to dimensioning of restorations, the milling position in the blanks must also be taken into account when using multilayer zirconia as restorative material.

In-vitro performance of subtractively and additively manufactured resin-based molar crowns

PURPOSE

To compare the in-vitro performance and wear behavior of additively or subtractively fabricated resin-based composite molar crowns for temporary and permanent application.

MATERIALS AND METHODS

Identical molar crowns (n = 8 per group) were manufactured from materials for temporary or permanent application (3x temporary additive fabrication, 3x additive permanent fabrication, 1x temporary subtractive fabrication, 1x permanent subtractive fabrication). All crowns were adhesively bonded (Calibra Universal, Dentsply Sirona, USA) on standardized resin-based composite molars (FDI 46, P Pro temporary Crown & Bridge). Thermal cycling and mechanical loading (2 × 3000 × 5°C/55 °C, 2min, H₂0 dist., 1.2 × 10⁶ force 50N) were performed and fracture force was determined (v = 1 mm/min, Z010, Zwick, Germany). Mean wear, maximum wear, and roughness were investigated on polished (P1200) specimens (n = 8 per group, d = 8 mm) in a pin-on-block test (50N; 120000 cycles; 1.6Hz; H₂O). Statistics were performed by using one-way ANOVA, Bonferroni post-hoc-tests, and Pearson-correlation (α = 0.05).

RESULTS

All crowns survived TCML without failures. Fracture forces ranged from 1362.4 ± 182.4N to 2354.1 ± 373.3N for the additive temporary crowns, from 1680.4.4 ± 525.1N to 2601.6 ± 403.7N for the additive permanent crowns, and reached values of 2988.5 ± 604.7N for subtractive temporary crowns and 3092.0 ± 307.6 N for subtractive permanent crowns. Significant (p < 0.001) differences were identified between the various additively manufactured systems, but not for the subtractively fabricated systems (p = 0.673). Mean wear of the additive temporary crowns ranged between 114.5 ± 25.8 μm and 163.8 ± 21.4 μm without significant differences (p = 0.061). Mean wear of the additive permanent crowns ranged between 120.0 ± 27.5 μm and 171.3 ± 31.8 μm with significant differences (p = 0.004). No statistically significant differences were identified between temporary and permanent subtractively manufactured specimens, with mean wear ranging between 140.5 ± 51.1 μm and 176.6 ± 26.8 μm (p = 0.673). Maximum wear of additive temporary specimens ranged between 221.4.5 ± 53.3 μm and 322.1 ± 50.6 μm; significant differences were identified between the groups (p = 0.016). Maximum wear of additive permanent specimens ranged between 246.3 ± 47.3 μm and 337.4 ± 61.4 μm, and significant differences were identified between the groups (p = 0.006). Mean wear of the subtractive group (permanent and temporary) showed no differences in maximum wear from 277.9 ± 79.7.1 μm to 316.4 ± 58.1 μm (p = 0.288). Ra roughness ranged from 0.7 ± 0.2 μm to 3.6 ± 1.3 μm with significant differences (p < 0.001) and Rz reference between 65.9 ± 26.2 μm and 16.8 ± 6.3 μm.

CONCLUSION

Temporary and permanent molar crowns provided at least acceptable in-vitro performance and fracture force for clinical mid-term application. Laboratory wear stability of the resin-based materials appeared sufficient, but should be verified under clinical conditions.

Dependence of the survival of 3D-printed temporary materials on the filler content

AIM

The aim of this in vitro study was the evaluation of the in-vitro performance and fracture force of 3D-printed anterior implant-supported temporary partial dentures (TPD) with different filler content.

MATERIALS AND METHODS

Identical anterior resin-based TPDs (tooth situation 11-13; n=8 per material) were 3D-printed of methacrylate resins with different filler content. A cartridge polymethacrylate (PMMA) material was used as a reference. After temporary cementation, combined thermal cycling and mechanical loading (TCML) was performed on all restorations to mimic clinical application. Behavior during TCML and fracture force was determined and failures were analyzed. Data were statistically investigated (Kolmogorov- Smirnov-test, one-way-ANOVA; post-hoc-Bonferroni, Kaplan-Meier-survival, α=0.05).

RESULT

Failure during TCML varied between three failures and total failure during loading time. Mean survival time varied between 93±206 x10³ cycles and 329±84 x10³ cycles. Significant different survival cycles between individual materials could be determined (Log Rank test Mantel Cox: Chi2 21,861, df =4, p<0.001). A correlation between filler level and survival cycles could be found (Pearson: 0.186, p=0.065). Fracture values of the surviving TPDs varied between 499 N and 835 N. Failures were characterized by fracture of the connector (n=24) followed by fractures at the abutment (n=10).

CONCLUSION

TDPs showed different filler-dependent survival. Individual 3D-printed materials provided comparable or even better performance than a standard cartridge system, and might be sufficient for temporary application of at least half a year.

Impact of the occlusal contact pattern and occlusal adjustment on the wear and stability of crowns

OBJECTIVES

To investigate the impact of the occlusal contact situation and occlusal adjustment on wear, roughness, and fracture force of molar crowns.

MATERIALS AND METHODS

CAD/CAM crowns (lower right first molar, n = 64; 4 groups à 8, 3Y-TZP zirconia and resin composite) and corresponding antagonists (upper right first molar; 3Y-TZP zirconia) were manufactured. Crowns were constructed according to two principles of occlusion (group "T": Peter K. Thomas' "point-centric" cusp-to-fossa tripodization concept, with 15 contact points; group "RA" Sigurd P. Ramfjord and Major M. Ash, "freedom in centric" concept with four contacts). On one half of the crowns, occlusal adjustment was performed (groups "T adjusted" and "RA adjusted"). All crowns underwent combined thermal cycling (TC) and mechanical loading (ML) (ML: 1.2 × 10⁶ cycles, 50 N, 2 Hz, mouth opening 1 mm; TC: 2 × 3000 cycles, 5/55°C). Wear area and depth of each contact point on the occlusal surfaces of crowns and antagonists were determined using a digital microscope. Surface roughness (R_a, R_z) was measured in and besides (reference) the worn area (3D laser-scanning microscope). Fracture force of the crowns was determined (statistics: Levene-test, one-way-ANOVA; Bonferroni-post-hoc-test; between-subjects effects, Pearson correlation, α=0.05).

RESULTS

The resin composite crowns yielded significantly higher mean values for wear area and depth (p < 0.001) and lower fracture forces (p < 0.001). Resin composite surfaces showed increased roughness after TCML while zirconia exhibited smoothened surfaces. The occlusal design significantly impacted wear depth (p = 0.012) and fracture force (p < 0.001). Resin composite crowns with fewer contact points (group RA) showed more wear and lower fracture force. Adjusted resin composite crowns showed increased wear areas and depths (p = 0.009-0.013). For zirconia crowns, the adjustment impacted wear area (p = 0.013), wear depth (p = 0.008), and fracture force (p = 0.006), with adjusted zirconia crowns exhibiting more wear and lower maximum forces until fracture. Zirconia wear depth was also impacted by the occlusal design (p = 0.012). Antagonistic wear was influenced by the restorative material, the occlusal contact pattern, and the adjustment.

CONCLUSIONS

The investigated materials show strongly varying performances with zirconia being significantly influenced by the adjustment, while for resin composites, contact design and adjustment had a major impact.

CLINICAL RELEVANCE

The results show the necessity of adapting occlusal design and adjustment in order to improve roughness, wear, and stability of zirconia and resin composite crowns.

Pull-off behavior of hand-cast, thermoformed, milled and 3D printed splints

PURPOSE

To investigate the insertion/pull-out performance of splints produced by hand casting, thermoforming, milling, and 3D printing.

MATERIALS AND METHODS

A total of 120 identical mandibular splints (n = 8 per group) were manufactured with hand casting, thermoforming, milling, and 3D printing. The splints were stored in water at 37°C for 10 days and then placed onto cobalt-chromium arches and fixed on one side. Forces were applied to the other side (centric, perpendicular 50 N, 1 Hz) at two different positions (teeth 46 and 44/45) to pull out, and the test was then reset. The number of pull-out cycles until failure was recorded. The fracture behavior of the splints was investigated and characterized as fracture in the loading position, fracture at the fixation, or combined fracture. Splints were pulled off until fracture as a control (v = 1 mm/minute). Finite element analysis was used to verify the results. Statistical analyses were conducted with one-way-ANOVA, post hoc Bonferroni, Pearson correlation, and Kaplan-Meier log-rank tests (α = .05).

RESULTS

The mean pull-off cycles varied from 7,839 (V-Print) to 1,600,000 (Optimill) at the tooth 46 position and from 9,064 (Splint Flex) to 797,750 (Optimill) at the 44/45 position. Log-rank test showed significantly (P < .001) different pull-out cycles between the systems (χ2: 61,792 to 122,377). The thickness of the splints varied between 1.6 ± 0.2 mm (Splint Flex) and 2.3 ± 0.1 mm (V-Print Splint). Thickness and number of cycles were correlated (Pearson 0.164; P = .074). The pull-off forces of the control varied significantly (P ≤ .040), from 13.0 N (Keysplint) to 82.2 N (Optimill) at the tooth 46 position and from 25.2 N (Keysplint) to 139.0 N (Optimill) at the 44/45 position.

CONCLUSION

The milled and cast splints survived more pull-off cycles than the printed or thermoformed splints. The pull-out performance showed differences among the tested splint systems and indicated the influence of the material properties and the processing.

Fracture behavior of cantilever fixed dental prostheses fabricated from different zirconia generations

OBJECTIVE

The aim of this study was to compare the fracture behavior of cantilever fixed dental prostheses (FDPs) fabricated from 3Y-TZP, 4Y-TZP, or 5Y-TZP zirconia.

METHOD AND MATERIALS

Posterior cantilever FDPs (three groups, each n = 16) were digitally designed and milled. After sintering, eight specimens/group were stored in demineralized water for 72 hours; eight specimens/group were subjected to accelerated aging using chewing simulation with thermal cycling (1,200,000 × 50 N; 2 × 3,000 × 5°C/55°C; H2O, 2 minutes/cycle) and finally stored in demineralized water for 24 hours. The cantilever FDPs were then statically loaded to failure to determine fracture load. Phase transformation towards the monoclinic phase was controlled with x-ray diffractometry.

RESULTS

One failure was identified after accelerated aging in the 5Y-TZP group. Fracture load decreased with increasing yttria content and decreasing bending strength. Accelerated aging using chewing simulation with thermal cycling caused a significant decline in fracture load. All FDPs failed in the area of the prepared tooth and in proximity to the cantilever, where the largest bending moment occurred. The yttria content had no influence on the type of fracture. With increasing yttria content, the relation between deformation and fracture load decreased only slightly. On the surface of FDPs that had been subjected to chewing simulation, no phase transformation towards the monoclinic phase (eg, low temperature degradation) was detected.

CONCLUSION

Within the limitations of a laboratory study, the data indicate that 3Y-, 4Y-, and 5Y-TZP may be employed as material for the fabrication of permanent posterior cantilever FDPs. However, more data are necessary to finally advocate the application of 5-Y-TZP. (Quintessence Int 2022;53:414-422; doi: 10.3290/j.qi.b2793243).

Cytotoxicity of printed resin-based splint materials

OBJECTIVES

Printed splints may be an alternative as a treatment of functional disorders in addition to physical, manual and physiological therapeutics. The objective is to investigate whether different 3D printed splint materials, which are fabricated with different fabrication orientation and post-processing (washing and post polymerisation) exhibit different in vitro cytotoxicity.

MATERIAL AND METHODS

600 discs (n = 25 per group, 5mmx1mm) were printed (P30+ DLP-printer, Straumann, CH; 100 µm layer) from splint materials (M1: Luxaprint OrthoPlus, DMG, G; M2: V-Print Splint, Voco, G). Printing was performed under 90° (A1), 45° (A2) or 0° (A3) alignment to the building platform. Specimens were either automatically washed (W1) (Straumann P Wash, Straumann, CH) or manually cleaned (W2) (Voco Pre-/Main-Clean protocol, Voco, G), and post polymerization was performed (P1: Cure, Straumann, CH; P2: Otoflash N171, Ernst Hinrichs Dental, G). RAW264.7 mouse macrophages were exposed to extracts of the specimens and cytotoxicity was determined as cell survival using a crystal violet assay. Optical density values obtained from exposed cell cultures were normalized to untreated controls (100%), summarized as means and statistically analyzed (ANOVA, α=0.05).

RESULTS

Cell survival varied between 9.1+/-1.3% (alignment A2/post cure P2/material M2/wash system W2) and 58.5+/-5.9% (alignment A1/post cure P1/material M1/wash system W1). Univariate analysis of variance revealed significant differences between mean values for post cure (p = 0.000), wash system (p = 0.002) and materials (p = 0.000), but not for the alignment (p = 0.406). With standardised washing and adapted post cure, both tested materials provided lowest cytotoxicity even in all three printing alignments.

CONCLUSIONS

The selection of the material as well as the post-processing (post-polymerization, washing procedure) show influence on the in vitro cytotoxicity. Alignment during manufacturing does not affect toxicity.

CLINICAL RELEVANCE

Materials, washing and post-polymerization should be matched to reduce cytotoxic effects during additive manufacturing.

In Vitro Mastication Simulation and Wear Test of Virgilite and Advanced Lithium Disilicate Ceramics

PURPOSE

To compare wear behavior, durability during in vitro mastication simulation, and fracture force of an established and a novel lithium disilicate CAD/CAM material, as well as to examine the impact of cementation and reduced ceramic thickness on durability and fracture force.

MATERIALS AND METHODS

Specimens (n = 8 per group) were prepared from lithium disilicate (LS₂; IPS e.max, Ivoclar Vivadent) and advanced lithium disilicate (ALD; Cerec Tessera, Dentsply Sirona). Specimens were polished, and two-body wear test and thermocycling were performed (50 N, 120,000 cycles, 1.6 Hz, H₂O dist., 5°C/55°C, 600 cycles). Maximum vertical loss, surface roughness, surface roughness depth, and antagonist wear were determined. Single crowns (n = 8 per group; thickness 1.5 mm/1.0 mm) were manufactured from LS₂ and ALD and mounted on human molar teeth with adhesive resin (AB; CalibraCeram, Dentsply Sirona), glass-ionomer cement (GIC; Ketac Cem, 3M ESPE), and hybrid glass-ionomer cement (HGIC; Calibra Bio, Dentsply Sirona). Thermocycling and mechanical loading (2 × 3000 × 5°C/55°C, 2 minutes, H₂0 dist., 1.2 × 10⁶ 50 N) were performed. Fracture force was determined by a universal testing machine (1446, ZwickRoell), and one-way analysis and Bonferroni post hoc test (α = .05) were used for statistical analyses.

RESULTS

Mean (ALD: 210 ± 42.4 μm; LS₂: 264.3 ± 56.1 μm) and maximum (ALD: 391.1 ± 86.3 μm; LS₂: 518.3 ± 113.2 μm) wear between groups were significantly different (P ≤ .047). Fracture force varied between 1,911.4 ± 468.4 N (ALD/AB 1 mm) and 2,995.3 ± 880.6 N (LS₂/GIC), without significant differences (P ≥ .152).

CONCLUSION

ALD showed better wear behavior than LS₂, but provided similar fracture force. Cementation and reduction of ceramic thickness had only minor effects on fracture force.

In vitro performance of CAD/CAM and conventional removable dentures

AIM

Innovations in CAD/CAM technology and materials science offer new methodologies for removable prosthodontics. As clinical data are still rare, in vitro performance of both CAD/CAM and comparable conventional materials may help to estimate the clinical outcome.

MATERIALS AND METHODS

Specimens (n = 8 per group) from teeth (CediTEC, SR VivodentCAD, Vitapan), base materials (V-Print dentbase, IvoBase CAD, Paladur), adhesives (CediTEC Primer/Adhesive, IvoBase CAD Bond), and a fully printed specimen (Try-In) were created. All specimens underwent thermal cycling and mechanical loading (TCML): 1,200,000 × 50 N; 2x3000 x 5°C/55°C; H2O. Surviving specimens were loaded to fracture. Statistical tests used were the Shapiro-Wilk test and the Kaplan-Meier survival, with the level of significance set to α = 0.05.

RESULTS

Mean loading cycles until failure varied between 100 and 621,667 cycles. Up to five specimens per group failed during TCML. With one exception, all specimens of the entirely CAD/CAM-fabricated group survived TCML. The log-rank (Mantel-Cox) test showed significantly different (P = 0.000) loading cycles between the systems (chi-square test: 28,247; degree of freedom: 8). Failure of the dentures during TCML was characterized by failure of the denture base (2x), denture tooth (13x), mixed base/tooth (3x) or adhesive between base and tooth (1x).

CONCLUSION

TCML and fracture testing showed different aspects of denture tooth restoration. The results indicated no correlation between fracture force, fracture pattern, and survival cycles. Denture teeth (milled, heat-pressed), bases (milled, printed, pressed), and primer should be matched up to optimize the performance of dentures.

Dynamic fatigue of 3D-printed splint materials

OBJECTIVES

Printed splints may be an alternative treatment for functional disorders. In addition to the selection of materials, the influence of cleaning or polymerisation can affect the dynamic behaviour and fatigue limit of printed materials.

MATERIAL AND METHODS

96 discs (n = 6 per group, 16mmx2mm) were printed (P30+ DLP-printer, Straumann, CH; 100 μm layer) from splint materials (M1: Luxaprint OrthoPlus, DMG, G; M2: V-Print Splint, Voco, G). Specimens were either automatically cleaned (C1: Straumann P Wash, Straumann, CH) or manually cleaned (C2: Voco Pre-/Main-Clean protocol, Voco, G). Post polymerisation was performed with LED (P1: Cure, Straumann, CH) or Xenon light (P2: Otoflash N171, Ernst Hinrichs Dental, G). The flexural fatigue limit was determined under cyclic loading in terms of a staircase approach with a piston-on-3-ball-test according to ISO 6872 after 24 h or 60 days water storage (37 °C). Specimens were preloaded with 50N and dynamic force was applied for 10⁵ loadings per step (f = 3Hz; steps 1: 50N-100N, 2: 50N-150N, 3: 50N-200N, 4: 50N-250N; F1000, Prematec, G; water at 37 °C).

STATISTICS

Kaplan Maier Log Rank (Mantel-Cox) test, ANOVA, Pearson correlations, Levene-test (α = 0.05, SPSS 26.0, IBM, Armonk, NY, USA)).

RESULTS

Mean survival cycles after 24 h of storage varied between 40388 (M1C2P2) and 195140 (M2C2P1) cycles and after 60 d decreased to 14022 (M1C2P2) and 173237 (M2C1P1). Kaplan Maier Log Rank test revealed significant differences between the material combinations. For M1 cleaning (Pearson: 0.346, p = 0.016) and for M2 polymerisation (Pearson: 0.616, p = 0.000) significantly influenced the number of loading cycles. Intermediate effects were found for material (p = 0.026), cleaning (p = 0.024) and polymerisation (p = 0.000) as well as the combination of material and polymerisation (p = 0.008).

CONCLUSIONS

The results show that the number of possible loading cycles of additively manufactured splint specimens depends on the type of material, their cleaning and post-polymerisation.

CLINICAL SIGNIFICANCE

Materials, cleaning and post-polymerisation of additive manufacturing processes should be matched to improve dynamic loading performance of splint materials.

Investigating the mechanical and optical properties of novel Urethandimethacrylate (UDMA) and Urethanmethacrylate (UMA) based rapid prototyping materials

OBJECTIVE

This study is focused on testing experimental rapid prototyping materials for occlusal splints made from Urethandimethacrylate (UDMA) and Urethanmethacrylate (UMA).

METHODS

Materials were mixed from UDMA and UMA in ratios of 1.0:0.0, 0.75:0.25, 0.5:0.5, 0.25:0.75 and 0.0:1.0. Specimens were printed using digital light processing (DLP). After post-processing, the specimens underwent testing on flexural strength, modulus of elasticity, hardness, wear behavior, surface roughness, gloss and color stability. All tests were performed after 24 h (baseline) and 10 days of water storage (aging). Splints underwent cyclic pull-off and insertion testing, which was alongside simulated using finite element analysis.

RESULTS

The mechanical properties were significantly influenced by changes in the UDMA:UMA ratio. Statistical analysis revealed that increased amounts of UMA correlated with a decrease in flexural strength (92.0 to 30.7 MPa), modulus of elasticity (2.4 to 0.6 GPa), hardness (155.1 to 102.0 N/mm²) and wear resistance (-1394.9 to -1742.1 μm). Materials with higher amounts of UMA were also more likely to be influenced by water storage. Specimens with 75% and 100% UMA content were partly not analyzable due to soft consistency. Optical properties showed only minor influence from UMA content and aging. Differences in surface roughness (3.9 to 2.4 μm) and color stability were insignificant. Gloss was partly influenced by the UDMA:UMA ratio and water storage. Mean survival rates for cyclic pull-off and insertion testing ranged from 2537 to 23,857 cycles. A correlation between the amount of UMA and survival rates was observed.

SIGNIFICANCE

The addition of up to 25% UMA showed promising results, complying with clinical standards and delivering acceptable results in the cyclic pull-off and insertion test. Further investigation on increments between 0 and 25% UMA could help to find an optimum.

Curvature-dependent shear bond strength of different attachment materials for orthodontic lingual indirect bonding

To evaluate the shear bond strength (SBS) of different attachment materials used for lingual bonding, the influence of artificial aging and the radii of curvature of the enamel surface on SBS, 192 third molars were photographed to determine the radius of curvature of the oral surface. After phosphoric acid etching a cylindrical test piece was bonded to the oral enamel using a mold that was filled with a chemically curing (Maximum Cure, Transbond IDB Premix) or a dual-curing (Nexus NX3, RelyX Unicem2) attachment material. SBS was tested after 24 h, 500 thermal cycles or 90 days at 37 °C with a universal testing machine. Computed tomography scans were performed to determine the bonded surface and calculate SBS. Values ranged from 8.3 to 20.9 MPa. RelyX Unicem2 showed the highest SBS values at baseline, 500 thermal cycles and after 90 days (p < 0.001). Ninety days of wet storage significantly reduced SBS of Maximum Cure (p = 0.028). The radius of curvature correlated positively with SBS (r_s = 0.204, p = 0.005). The SBS of all attachment materials was sufficient for clinical use, even after artificial aging. RelyX Unicem2 showed almost twice as high SBS values as the other attachment materials.

Correction to: Temporary materials: comparison of in vivo and in vitro performance

A Correction to this paper has been published: https://doi.org/10.1007/s00784-021-04067-4

Long-term clinical performance and complications of zirconia-based tooth- and implant-supported fixed prosthodontic restorations: A summary of systematic reviews

OBJECTIVES

To present an overview on systematic reviews on prosthodontic zirconia restorations and to discuss long-term complications as well as information on anatomical and functional changes to the masticatory system.

DATA/SOURCES

MEDLINE, EMBASE, Trip medical, and Cochrane Library databases were searched for systematic reviews up to February 2021. Bias was assessed and clinical survival and complications were analyzed.

STUDY SELECTION

38 eligible articles published between 2006 and 2021 were included. The reviews were based on 128 in vivo studies on approximately 10,000 zirconia restorations. 5-year cumulative survival rates varied between 91.2% and 95.9% for tooth-supported (TS) single crowns (SC), 89.4% and 100% for TS multi-unit fixed dental prostheses (FDP), 97.1% and 97.6% for implant-supported (IS) SCs and 93.0% and 100% for IS FDPs. Chipping was the most often technical complication, followed by framework fracture, loss of retention, marginal discrepancies/discoloration, occlusal roughness and abutment/screw loosening. Color mismatch was the only esthetic complication. Biological complications were caries, endodontic complications, tooth fracture, periodontal disease, abrasion/attrition, persisting pain, high sensitivity, peri‑implantitis and soft tissue issues. Patients with bruxism were only examined sporadically.

CONCLUSIONS

5-year results for zirconia restorations were satisfactory. The predominant technical problem of veneering fractures could be overcome with adapted design or fabrication and application of monolithic restorations, but reviews of clinical studies on this subject are rare. The impact of zirconia restorations on the masticatory system remains unclear.

CLINICAL SIGNIFICANCE

Zirconia restorations are experiencing a rapidly increasing use in dental practice. Being highly wear-resistant, hard and durable, it can be assumed that they do not follow natural abrasion and changes in the masticatory system. Possible long-term effects on the stomatognathic system as a whole should therefore be considered.

Machine-driven simulation of removing luting agent remnants from implant surfaces: An investigator-independent assessment of cleaning protocols

INTRODUCTION

To simulate removing luting agent remnants from crowns fixed onto implant-abutment analogs using a standardized machine-driven protocol including a scaler and air polishing or sonic.

MATERIAL AND METHODS

A motor-driven device was constructed that controlled the rotational speed of the specimens, machining distance, contact pressure, and working time. A standardized layer of cement (Provicol, VOCO; Cuxhaven, G; Ketac Cem, 3MEspe; Seefeld, G; or Rely X Unicem, 3MEspe, Seefeld, G) was placed onto the finishing line of the crowns luted onto titanium-abutment analogs. The cement layer was scaled with a fresh titanium scaler maneuvered by the motor-driven device and treated with air polishing or sonic. Protocol 1: Scaling only for 20s, 40s, or 60s; n=20; protocol 2: 40s of scaling plus 20s of air polishing; protocol 3: 20s of scaling plus 40s of air polishing; protocol 4: 20s of scaling plus 40s of sonic; protocol 5: 40s of scaling plus 20s of sonic; protocols 2-5: n=10. Cement remnants were counted digitally as "percentage of remnants".

STATISTICS

mean, standard deviation, Bonferroni post hoc tests; α=0.05.

RESULTS

Ketac Cem was easily removed by scaling only and Provicol by scaling and air polishing, but the self-adhesive resin composite cement Rely X Unicem was not removable with the device. Only remnants of Provicol could be significantly reduced by further treatment after scaling (p<0.001).

CONCLUSION

The presented motor-driven device enables reproducible investigations of various cleaning protocols and is thus useful to create an overview of cleaning protocols needed for the different types of cement.

In vitro performance and fracture resistance of pressed or CAD/CAM milled ceramic implant-supported screw-retained or cemented anterior FDPs

PURPOSE

This study investigated the in-vitro performance of anterior implant-supported fixed dental prostheses (FDP). The effect of ceramics, fabrication, finalization and the presence of a screw-channel wa s investigated.

METHODS

Identical anterior ceramic FDPs (tooth 11-13; n=80) were milled (Lithiumdisilicate (LiSiCAD, emaxCAD, Ivoclar-Vivadent), Lithiumaluminiumsilicate (LiAlSi, experimental material) or pressed (Lithiumdisilicate (LiSiPress, emaxPress, Ivoclar-Vivadent), Lithiumsilicate (ZLS, CeltraPress, Dentsply Sirona). FDP-groups (n=8 per material and group) simulated a cemented or screw-retained approach. After cementation or screwing on titanium abutments, thermal cycling and mechanical loading (TCML) was performed on all restorations to mimic 5-year clinical performance. Performance and fracture force were determined and failures were analyzed.

STATISTICS

(Kolmogorov-Smirnov-test, one-way-ANOVA; post-hoc-Bonferroni, multivariate-regression, α=0.05).

RESULTS

All FDPs survived TCML without aging, cracks, fractures or chipping. For FDPs without screw channel fracture values varied between with 839.8±112.3N (LiAlSi glazed) and 1485.9±232.6N (LiSiCAD). With screw channel, fracture results varied between 701.4±220.1N (LiALSi glazed) and 1516.3±253.7N (LiSipress). The type of material had a significant influence on the fracture results (LiSi>ZLS>LiAlSi; p≤0.012). Fabrication and finalization had no influence on the results. A screw channel did not significantly (p≥0.135) reduce the fracture force of the FDPs. Type of failure was mostly characterized by a fracture of the connector (LiSi, LiAlSi) or the abutment (ZLS, LiAlSi).

CONCLUSIONS

FDPs survived TCML without failures indicating that the in vitro performance was not influenced by the tested parameters. Composition of ceramic material has significant influence on the fracture resistance of implant supported LiSi based FDPs. Screw channel, fabrication or finalization did not weaken the FDPs.

Temporary materials: comparison of in vivo and in vitro performance

OBJECTIVE

The aim of this investigation was to compare clinical performance and in vitro wear of temporary CAD/CAM and cartridge crowns. This study is an approach to estimate the influence of in vivo use and laboratory simulation on temporary crowns.

MATERIALS AND METHODS

A total of 90 crowns were fabricated from each temporary CAD/CAM or cartridge material. Also, 10 crowns of each material were clinically applied for 14 days, and 80 identical duplicate restorations were investigated in the laboratory after storage in water (14 days; 37 °C) and subsequent thermal cycling and mechanical loading (TCML, 240.000 × 50N ML, 600 × 5°C/55 °C). After in vivo application or in vitro aging, facture force, superficial wear (mean and maximum), surface roughness (Ra, Rz), thermal weight loss (TGA), and heat of reaction (DSC) were determined for all crowns.

STATISTICS

Bonferroni post hoc test; one-way analysis of variance (ANOVA); α = 0.05).

RESULTS

The fracture resistance of the temporary materials varied between 1196.4 (CAD in vivo) and 1598.3 N (cartridge crown in vitro). Mean (maximum) wear data between 204.7 (386.7 μm; cartridge in vitro) and 353.0 μm (621.8 μm; CAD in vitro) were found. Ra values ranged between 4.4 and 4.9 μm and Rz values between 36.0 and 40.8 μm. DSC and TG analysis revealed small differences between the materials but a strong influence of the aging process.

CONCLUSIONS

Comparison of in vivo and in vitro aging led to no significant differences in fracture force and wear but differences in roughness, DSC, and TGA. SEM evaluation confirmed comparability. Comparison of CAD/CAM and cartridge temporary materials partially showed significant differences.

CLINICAL RELEVANCE

In vitro aging methods might be helpful to estimate materials' properties before principal clinical application. CAD/CAM and cartridge temporary materials provided comparable good clinical performance.

Stability of screw-retention in two-piece zirconia implants: An in vitro study

OBJECTIVES

To compare the stability of a screw-retained connection in a novel two-piece zirconia implant to a conventional titanium-based connection in an in vitro chewing simulation including artificial ageing.

MATERIAL AND METHODS

Incisor (I) and molar (M) shaped monolithic zirconia crowns were screw-retained on either two-piece zirconia (test) or two-piece titanium (control) implants resulting in 4 groups of 8 samples (titanium implants with incisor-shaped crowns (T-I), titanium implants with molar-shaped crowns (T-M), zirconia implants with incisor-shaped crowns (Z-I) and zirconia implants with molar-shaped crowns (Z-M). These were subjected to artificial ageing by thermal cycling (TC: 2 × 3000 × 5°C/55°C cycles of 2 min) and mechanical loading (ML: 1.2 × 10⁶ cycles of 50 N, f = 1 Hz). Surviving samples additionally underwent a fracture force test. Kaplan-Meier plots were drawn, and two-way ANOVA was calculated taking anatomical localisation and material variables as factors.

RESULTS

The mean corresponding survival times were lower for T-M (0.86 × 10⁶  ± 0.31 × 10⁶ cycles) and Z-I (0.84 × 10⁶  ± 0.21 × 10⁶ cycles) compared to T-I (1.14 × 10⁶  ± 0.10 × 10⁶ cycles) and Z-M (1.20 × 10⁶  ± 0.10 × 10⁶ cycles). In one-way ANOVAs for survival time dependent on either location or material, no statistically significant differences could be found (location: p = .31; material: p = .62) in one-way ANOVAs. The interaction of location and material showed significant differences (F = 21.3, p < .001).

CONCLUSION

The connection of the tested screw-retained zirconia crowns in two-piece zirconia implants is comparable to standard titanium implants in the specific in vitro testing.

Laboratory performance and fracture resistance of CAD/CAM implant-supported tooth-coloured anterior FDPs

OBJECTIVES

This study investigated the in-vitro performance and fracture force of anterior implant-supported tooth-coloured fixed dental prosthesis (FDPs). Different material types with varying flexural strength and modulus of elasticity were compared with screw-retained or bonded application.

MATERIALS AND METHODS

Identical anterior FDPs (tooth 11-13; n = 80) from materials (flexural strength 240-1150 MPa, modulus 7.6-210 GPa; 1x lithiumdisilicate ceramic, 2x zirconia (4Y-TZP, 5Y-FSZ), 3x resin-based composites (with different flexural strength and modulus)) were milled. FDPs were grouped into chairside (bonded) and labside (screw-retained) procedure. To simulate a 5-year clinical application, thermal cycling with mechanical loading (TCML) was accomplished. TCML-performance and fracture force were evaluated and failure patterns were analysed. Data were statistically investigated (Kolmogorov-Smirnov-test, one-way-ANOVA; post-hoc-Bonferroni, α = 0.05).

RESULTS

TCML did not lead to any cracks, fractures or chipping on all tested FDPs. Fracture values varied between 1208.9 ± 354.6 N (experimental resin-based composite) and 2094.3 ± 293.4 N (4Y-TZP) for FDPs without screw channel. With screw channel the results ranged between 1297.9 ± 268.3 N (5Y-FSZ) and 2129.3 ± 321.7 N (4Y-TZP). The influence of the screw channel was not significant for all materials (p ≥ 0.218). Modulus of elasticity and flexural strength had influence on the fracture force only in the individual material groups. Fractures at the connector were predominant for ceramic and zirconia. Resin-based composites primarily showed radial fractures in abutment region or mixed failure types. FDPs with/without screw-channel showed comparable types of failure.

CONCLUSIONS

TCML did not lead to drop-outs or failures for all FDPs. Individual materials showed no different in-vitro performance, but varying fracture force after TCML. Independent from material, screw channels did not weaken the FDPs. All tested systems showed sufficient properties for an anterior implant application.

Influence of zirconia and lithium disilicate tooth- or implant-supported crowns on wear of antagonistic and adjacent teeth

PURPOSE

To investigate the influence of crown material (lithium-disilicate, 3Y-TZP zirconia) and abutment type (rigid implant, resin tooth with artificial periodontium) on wear performance of their antagonist teeth and adjacent teeth.

MATERIALS AND METHODS

A mandibular left first molar (#36) with adjacent human teeth (mandibular left second premolar: #35, mandibular left second molar: #37) and antagonistic human teeth (maxillary left second premolar: #25, maxillary left first molar: #26, maxillary left second molar: #27) was prepared simulating a section of the jaw. Samples were made with extracted human molars (Reference), crowned implants (Implant), or crowned resin tooth analogues (Tooth). Crowns (tooth #36; n = 16/material) were milled from lithium-disilicate (Li, IPS e.max CAD) or 3Y-TZP zirconia (Zr, IPS e.max ZirCAD, both Ivoclar Vivadent). Thermal cycling and mechanical loading (TCML) in the chewing simulator were applied simulating 15 years of clinical service. Wear traces were analyzed (frequency [n], depth [µm]) and evaluated using scanning electron pictures. Wear results were compared by one-way-ANOVA and post-hoc-Bonferroni (α = 0.05).

RESULTS

After TCML, no visible wear traces were found on Zr. Li showed more wear traces (n = 30–31) than the reference (n = 21). Antagonistic teeth #26 showed more wear traces in contact to both ceramics (n = 27–29) than to the reference (n = 21). Strong wear traces (> 350 µm) on antagonists and their adjacent teeth were found only in crowned groups. Abutment type influenced number and depth of wear facets on the antagonistic and adjacent teeth.

CONCLUSION

The clinically relevant model with human antagonistic and adjacent teeth allowed for a limited comparison of the wear situation. The total number of wear traces and strong wear on crowns, antagonistic and adjacent teeth were influenced by crown material.

Fracture force of CAD/CAM resin composite crowns after in vitro aging

OBJECTIVES

The aim of this in vitro study was to investigate the influence of material, preparation, and pre-treatment on the aging and fracture force of CAD/CAM resin composite molar crowns.

MATERIALS AND METHODS

CAD/CAM molar crowns (n = 80) were milled from four resin composites (Block HC, Shofu; Lava Ultimate, 3 M; Grandio Blocs, Voco; and Tetric CAD, Ivoclar Vivadent, with/without sandblasting). Extracted human teeth were prepared with optimal preparation (height 6-8 mm, angle 6-8°) or worst-case preparation (height 3.5-4 mm, angle 10-15°). Both groups were prepared with a 1-mm deep cervical circular shoulder. Crowns were adhesively bonded after corresponding tooth treatment required for the individual adhesive systems (Table 1). Specimens were aged for 90 days in water storage (37 °C) and subsequently subjected to thermal cycling and mechanical loading (TCML 3000 × 5 °C/3000 × 55 °C, 2 min each cycle, H20 distilled; 1.2 × 10⁶ cycles à 50 N, 1.6 Hz). De-bonding and fracture force was determined.

STATISTICS

one-way-ANOVA; post hoc Bonferroni, α = 0.05.

RESULTS

Four crowns of Lava Ultimate with worst-case preparation de-bonded during TCML. Individual crowns without sandblasting treatment (3x Tetric CAD with optimal preparation; 1x Tetric CAD with worst-case preparation) de-bonded during water storage. One crown of Grandio Blocs with optimal preparation showed a small chipping during TCML. All other crowns survived TCML and water storage without failure. Fracture forces differed between 1272 ± 211 N (Lava Ultimate) and 3061 ± 521 N (Tetric CAD). All Grandio Blocs and Tetric CAD crowns revealed significantly (p ≤ 0.023) higher fracture forces than Block HC or Lava Ultimate crowns. No significantly different (p > 0.05) fracture forces were found between optimal or worst-case preparation/fit groups.

CONCLUSIONS

De-bonding during water storage and TCML was dependent on material and crown pre-treatment. Therefore, surface roughening seems strongly required. Fracture forces were not influenced by preparation but by the type of material.

CLINICAL RELEVANCE

Clinical success and de-bonding of CAD/CAM resin composite crowns is strongly influenced by the type of material and its pre-treatment.

Validating laboratory simulation with resin-based materials for temporary fixed denture prostheses - Results from clinical and laboratory trials

The aim of the current study was to relate an artificial aging protocol for the analysis of dental materials to their clinical performance. 20 fixed interim restorations (crowns and fixed denture prostheses (FDPs)) fabricated from two commercially available resin-based composites (RBCs) and a previous clinical trial served as templates for the fabrication of duplicate restorations. Duplicates were subjected to artificial aging using thermal cycling and mechanical loading. Subsequent to wear analysis, templates and duplicates were loaded to fracture and were examined using thermal gravimetric analysis (TG) and differential scanning calorimetry (DSC). For both RBCs, a relevant uptake of water was identified, which was more pronounced in the duplicates. Tribological analyses indicated relevant signs of wear in both templates and duplicates. While qualitative analyses indicated macroscopically similar wear traces in templates and duplicates, data showed that wear of FDPs was underrated in the laboratory analyses. The results of the current study suggest that chewing simulation allows a proper estimation of aging processes in materials for the fabrication of fixed interim restorations. However, simulation parameters should be continuously improved using data derived from clinical settings to enhance the quality of the simulation protocols.

Influence of Heat Treatment and Veneering on the Storage Modulus and Surface of Zirconia Ceramic

Objectives: Glass-ceramic veneered zirconia is used for the application as fixed partial dentures. The aim of this investigation was to evaluate whether the heat treatment during veneering, the application of glass-ceramic for veneering or long term storage has an influence on the storage modulus of zirconia. Methods: Zirconia bars (Cercon, DeguDent, G; 0.5x2x20 mm) were fabricated and treated according to veneering conditions. Besides heating regimes between 680°C and 1000°C (liner bake and annealing), sandblasting (Al2O3) or steam cleaning were used. The bars were investigated after 90 days storage in water and acid. For investigating the influence of veneering, the bars were veneered in press- or layer technique. Dynamic mechanical analysis (DMA) in a three-point-bending design was performed to determine the storage modulus between 25°C and 200°C at a frequency of 1.66 Hz. All specimens were loaded on top and bottom (treatment on pressure or tensile stress side). Scanning electron microscopy (SEM) was used for evaluating the superficial changes of the zirconia surface due to treatment. Statistical analysis was performed using Mann Whitney U-test (α=0.05). Results: Sintered zirconia provided a storage modulus E’ of 215 (203/219) GPa and tan δ of 0.04 at 110°C. A 10%-decrease of E’ was found up to 180°C. The superficial appearance changed due to heating regime. Sandblasting reduced E’ to 213 GPa, heating influenced E’ between 205 GPa (liner bake 1) and 222 GPa (dentin bake 1). Steam cleaning, annealing and storage changed E’ between 4 GPa and 22 GPa, depending on the side of loading. After veneering, strong E’-reduction was found down to 84 GPa and 125 GPa. Conclusions: Veneering of zirconia with glass-ceramic in contrast to heat treating during veneering procedure had a strong influence on the modulus. The application of the glass-ceramic caused a stronger decrease of the storage modulus. (Eur J Dent 2011;5:191-198)

Direct or Indirect Restoration of Endodontically Treated Maxillary Central Incisors with Class III Defects? Composite vs Veneer or Crown Restoration

PURPOSE

The aim of this ex-vivo study was to evaluate the load capacity of direct or indirect endodontically restored maxillary central incisors with Class III defects, with or without glass-fiber posts.

MATERIALS AND METHODS

Seventy-two extracted human maxillary central incisors were endodontically treated and bi-proximal Class III cavities were prepared. Specimens were randomly allocated to six groups (n = 12): direct restoration with composite (C); direct restoration with composite and additional glass-fiber post (CP); ceramic veneer restoration (V), ceramic veneer restoration and additional glass-fiber post (VP), ceramic crown restoration (Cr), ceramic crown restoration and additional glass-fiber post (CrP). Specimens were exposed to thermomechanical loading (TML: 1.2 million cycles, 1 to 50 N; 6000 thermal cycles between 5°C and 55°C for 1 min each), and subsequently linearly loaded until failure (Fmax [N]) at an angle of 135 degrees 3 mm below the incisal edge on the palatal side. Statistical tests were performed using the Kruskall-Wallis and Mann-Whitney U-Test.

RESULTS

During dynamic loading by TML, one early failure occurred in group C, CP, and CrP. Subsequent linear loading resulted in mean fracture load values [N] of C = 483 ± 219, CP = 536 ± 281, V = 908 ± 293, VP = 775 ± 333, Cr = 549 ± 258, CrP = 593 ± 259. The Kruskal-Wallis test showed significant differences of load capacity between groups (p < 0.05). Mann-Whitney U-test revealed significantly lower maximum fracture load values of group C compared to group V (p = 0.014), after Bonferroni-Holm correction. Non-restorable root fracture was the most frequent type of failure.

CONCLUSION

Endodontically treated maxillary central incisors with Class III defects directly restored with composite are as loadable as indirect crown restorations. Compared to full-coverage restorations, less invasive veneers appear to be more beneficial. Additional placement of glass-fiber posts shows no positive effect.

Performance of resin materials for temporary fixed denture prostheses

This study investigated the handling properties and clinical performance of two commercially available resin materials with slight differences in filler composition for the fabrication of fixed interim restorations. In a dental university setting, patients requiring prosthetic treatment were supplied with fixed interim restorations fabricated from two commercially available resin materials. To clarify the handling properties of the resin materials, dentists and undergraduate students completed a questionnaire. Prior to insertion of the definitive restoration, the interim restorations were analyzed by calibrated examiners using a modification of the United States Public Health Service criteria. Eighty-two fixed interim restorations with a mean clinical service period of 44.5 (±28.3) days were included, including 39 single crowns, 30 fixed denture prostheses, 10 blocked crowns, and 3 partial coverage restorations. No significant differences between the two materials in the rating of their handling properties were identified, with the exception of the parameter "surface". Failures due to fractures were observed in 13% of the interim restorations. No significant differences between the materials in the rating of the clinical performance were identified. These results indicate that slight changes in the filler composition of commercial formulations account for few differences in handling properties and clinical performance.

Investigation of Clinical and Laboratory Wear in Locator-Supported, Implant-Retained Overdentures

PURPOSE

To investigate the mechanical properties and wear of nylon inserts and abutments in Locator-retained, implant-supported overdentures (L-IODs).

MATERIALS AND METHODS

Clinical wear of inserts and abutments was qualitatively rated in a group of 16 patients with L-IODs. The inserts were also subjected to microscopic analysis, differential scanning calorimetry (DSC), and thermal gravimetric analysis (TGA).

RESULTS

Wear was identified in almost all inserts and abutments. These results were corroborated by DSC and TGA analyses, which showed significant mechanical deterioration of the inserts.

CONCLUSION

Nylon inserts and Locator abutments show relevant signs of deterioration in clinical use, indicating that regular maintenance is an issue that should be addressed with the patients prior to treatment.

Failure loads of all-ceramic cantilever fixed dental prostheses on post-restored abutment teeth: influence of the post presence and post position

The influence of a fiber post-restored abutment tooth on the load capability of a three-unit zirconia framework cantilever fixed dental prosthesis (cFDP) was evaluated after simulated clinical function. Human lower sound premolars (n = 64) were distributed, in equal numbers, to four experimental groups: two vital abutment teeth (group I; control); mesial abutment tooth post-restored (group II); distal abutment tooth post-restored (group III); and mesial and distal abutment teeth post-restored (group IV). All specimens received an adhesively luted three-unit cFDP of veneered zirconia. Simulated clinical function was performed by two subsequent sequences of thermal-cycling (2 × 3,000 cycles) and mechanical loading (1.2 × 10⁶ load cycles from 0 to 50 N) (TCML). Four specimens failed during TCML (one in each of groups I and IV and two in group II). The maximum load capability ranged from 365 to 538 N and was not significantly different between groups. Specimens with post-restored abutments failed mainly because of abutment tooth fracture of the distal abutment. The presence or position of post-restored abutment teeth has no significant impact on load capability of all-ceramic three-unit cFDPs. The risk of tooth fracture of the distal abutment teeth of a cFDP was significantly increased when one abutment tooth, irrespective of its position, was post-and-core restored.

In vitro performance and fracture resistance of novel CAD/CAM ceramic molar crowns loaded on implants and human teeth

PURPOSE

To investigate the fatigue and fracture resistance of computer-aided design and computer-aided manufacturing (CAD/CAM) ceramic molar crowns on dental implants and human teeth.

MATERIALS AND METHODS

Molar crowns (n=48; n=8/group) were fabricated of a lithium-disilicate-strengthened lithium aluminosilicate glass ceramic (N). Surfaces were polished (P) or glazed (G). Crowns were tested on human teeth (T) and implant-abutment analogues (I) simulating a chairside (C, crown bonded to abutment) or labside (L, screw channel) procedure for implant groups. Polished/glazed lithium disilicate (E) crowns (n=16) served as reference. Combined thermal cycling and mechanical loading (TC: 3000×5℃/3000×55℃; ML: 1.2×10⁶ cycles, 50 N) with antagonistic human molars (groups T) and steatite spheres (groups I) was performed under a chewing simulator. TCML crowns were then analyzed for failures (optical microscopy, SEM) and fracture force was determined. Data were statistically analyzed (Kolmogorow-Smirnov, one-way-ANOVA, post-hoc Bonferroni, α=.05).

RESULTS

All crowns survived TCML and showed small traces of wear. In human teeth groups, fracture forces of N crowns varied between 1214±293 N (NPT) and 1324±498 N (NGT), differing significantly (P≤.003) from the polished reference EPT (2044±302 N). Fracture forces in implant groups varied between 934±154 N (NGI_L) and 1782±153 N (NPI_C), providing higher values for the respective chairside crowns. Differences between polishing and glazing were not significant (P≥.066) between crowns of identical materials and abutment support.

CONCLUSION

Fracture resistance was influenced by the ceramic material, and partly by the tooth or implant situation and the clinical procedure (chairside/labside). Type of surface finish (polishing/glazing) had no significant influence. Clinical survival of the new glass ceramic may be comparable to lithium disilicate.

Stability of Implant-Abutment Connection After Using the Rescue Kit: An In Vitro Study

PURPOSE

To evaluate whether removing a fractured abutment screw with a specific rescue device negatively affects the success of a new restoration in terms of early abutment loosening.

MATERIALS AND METHODS

Implants (n = 10) with a regular platform of 4.1 mm (tissue level [TL]) and implants (n = 10) with a reduced diameter of 3.3 mm (bone level [BL]) were used. The screws of eight respective abutments for both implant types were artificially weakened in order to fracture during torque application for abutment insertion. The fractured abutment screws were removed applying a specific rescue kit. The implant inner threads were cleaned and remodeled with a system-specific tapper. New abutments were inserted, and computer-aided design/computer-aided manufactured (CAD/CAM) full zirconia crowns were luted. Aging by thermal cycling and mechanical loading was performed with a customized masticator simulator, and the number of crown and/or abutment loosenings was determined. In cases in which no loosening was observed, sawing and grinding were performed to determine the contact zone between the inner implant thread and abutment screw. Data were compared with a control group, eg, unmodified implant-abutment connections.

RESULTS

No abutment loosening was observed. All crowns were in function after mastication simulation. The inner thread contact zones of both test groups were generally smaller than in the control group, with a mean contact area of 448.6 μm and 459 μm for BL implants, and 608.8 μm and 620.5 μm for the TL implants in test and control groups, respectively.

CONCLUSION

Removing a fractured abutment screw with a specific rescue device and modifying the inner thread seems not to negatively affect the functional connection between a new abutment and the implant.

Direct restoration of endodontically treated maxillary central incisors: post or no post at all?

OBJECTIVES

The aim of this ex-vivo study was to evaluate the impact of cavity size and glass-fiber post (GFP) placement on the load capability of endodontically treated maxillary incisors directly restored with resin composite.

MATERIALS AND METHODS

Ninety-six extracted human maxillary central incisors were endodontically treated and distributed to four groups (n = 24): access cavity (A), access cavity and uni-proximal class III cavity (U), access cavity and bi-proximal class III cavity (B), and decoronated tooth (D). Specimens were restored with resin composite, and 12 specimen of each group received an adhesively placed glass-fiber post (P). Prior to linear loading, specimens were exposed to thermo-mechanical loading (TCML). Statistical analysis was performed using log-rank test after TCML, Kruskall-Wallis and Mann-Whitney U test to compare load capabilities (F_max).

RESULTS

Significantly more failures occurred in group D for specimens without GFP during TCML (p = 0.001). F_max (mean (SD) in N was (A) 513 (124), (AP) 554 (201), (U) 438 (171), (UP) 537 (232) (B) 483 (219), (BP) 536 (281), D 143 (181), and DP 500 (331), and differed significantly among groups (p = 0.003). Pair-wise comparison revealed lower F_max values for group D compared to all other groups (p < 0.034) except group DP.

CONCLUSIONS

Endodontically treated maxillary central incisors with cavity sizes up to bi-proximal class III may be successfully directly restored with resin composite. Post placement shows no additional effect except for decoronated endodontically treated incisors.

CLINICAL RELEVANCE

Endodontically treated incisors with access cavities to class III cavities can be successfully restored with resin composite. Post placement for decoronated ETT is recommended.