Impact of Digital Tooth Preparation Evaluation Technology on Preclinical Dental Students' Technical and Self-Evaluation Skills.

The aim of this study was to evaluate the effect of digital tooth preparation imaging and evaluation technology on dental students' technical abilities, self-evaluation skills, and the assessment of their simulated clinical work. A total of 80 second-year students at one U.S. dental school were assigned to one of three groups: control (n=40), E4D Compare (n=20), and Sirona prepCheck (n=20). Students in the control group were taught by traditional teaching methodologies, and the technology-assisted groups received both traditional training and supplementary feedback from the corresponding digital system. Three outcomes were measured: faculty technical score, self-evaluation score, and E4D Compare scores at 0.30 mm tolerance. Correlations were determined between the groups' scores from visual assessment and self-evaluation and between the visual assessment and digital scores. The results showed that the visual assessment and self-evaluation scores did not differ among groups (p>0.05). Overall, correlations between visual and digital assessment scores were modest though statistically significant (5% level of significance). These results suggest that the use of digital tooth preparation evaluation technology did not impact the students' prosthodontic technical and self-evaluation skills. Visual scores given by faculty and digital assessment scores correlated moderately in only two instances.

Effect of Computer-Assisted Learning on Students' Dental Anatomy Waxing Performance.

The aim of this study was to evaluate the impact of computer-assisted learning on first-year dental students' waxing abilities and self-evaluation skills. Additionally, this study sought to determine how well digital evaluation software performed compared to faculty grading with respect to students' technical scores on a practical competency examination. First-year students at one U.S. dental school were assigned to one of three groups: control (n=40), E4D Compare (n=20), and Sirona prepCheck (n=19). Students in the control group were taught by traditional teaching methodologies, and the technology-assisted groups received both traditional training and supplementary feedback from the corresponding digital system. Five outcomes were measured: visual assessment score, self-evaluation score, and digital assessment scores at 0.25 mm, 0.30 mm, and 0.35 mm tolerance. The scores from visual assessment and self-evaluation were examined for differences among groups using the Kruskal-Wallis test. Correlation between the visual assessment and digital scores was measured using Pearson and Spearman rank correlation coefficients. At completion of the course, students were asked to complete a survey on the use of these digital technologies. All 79 students in the first-year class participated in the study, for a 100% response rate. The results showed that the visual assessment and self-evaluation scores did not differ among groups (p>0.05). Overall correlations between visual and digital assessment scores were modest though statistically significant (5% level of significance). Analysis of survey responses completed by students in the technology groups showed that profiles for the two groups were similar and not favorable towards digital technology. The study concluded that technology-assisted training did not affect these students' waxing performance or self-evaluation skills and that visual scores given by faculty and digital assessment scores correlated moderately.

Internal fit of pressed and computer-aided design/computer-aided manufacturing ceramic crowns made from digital and conventional impressions.

STATEMENT OF PROBLEM: No studies have evaluated the internal adaptation of pressed and milled ceramic crowns made from digital impressions. PURPOSE: The purpose of this in vitro study was to evaluate the internal fit of pressed and milled ceramic crowns made from digital and conventional impressions. MATERIAL AND METHODS: Thirty polyvinyl siloxane (PVS) impressions and 30 Lava COS impressions made of a prepared dentoform tooth (master die) were fabricated. Thirty crowns were pressed in lithium disilicate (IPS e.max Press), and 30 crowns were milled from lithium disilicate blocks (IPS e.max CAD) (15/impression technique) with the E4D scanner and milling engine. The master die and the intaglio of the crowns were digitized with a 3-dimensional laser coordinate measurement machine. The digital master die and intaglio of each crown were merged. The distance between the die and the intaglio surface of the crown was measured at 3 standardized points. One-way ANOVA was used for statistical analysis (α=.05). RESULTS: One-way ANOVA revealed that the internal gap obtained from the Lava/press group (0.211 mm, ±SD 0.041) was significantly greater than that obtained from the other groups (P<.001), while no significant differences were found among PVS/press (0.111 mm ±SD 0.047), PVS/CAD/CAM (0.116 mm ±SD 0.02), and Lava/CAD/CAM (0.145 mm ±SD 0.024). CONCLUSIONS: The combination of the digital impression and pressed crown produced the least accurate internal fit.

Dental anatomy grading: comparison between conventional visual and a novel digital assessment technique.

Conventional grading of dental students' projects in preclinical courses has mainly relied on visual evaluation by experienced instructors. The purpose of this study was to compare conventional visual grading in a dental anatomy course at one U.S. dental school to a novel digital assessment technique. A total of sixty samples comprised of two sets of faculty wax-ups (n=30), student wax-ups (n=15), and dentoform teeth of tooth #14 (n=15) were used for this study. Two additional faculty members visually graded the samples according to a checklist and then repeated the grading after one week. The sample wax-up with the highest score based on the visual grading was selected as the master model for the digital grading, which was also performed twice with an interim period of one week. Descriptive statistics and signed rank tests for systematic bias were used for intra- and interrater comparisons. The intraclass correlation (ICC) was used as a measure of intra- and interrater reliability. None of the faculty members achieved the minimum acceptable intrarater agreement of 0.8. Interrater agreement was substantially less than intrarater agreement for the visual grading, whereas all measures of intrarater agreement were greater than 0.9 and considered excellent for the digital assessment technique. These results suggest that visual grading is limited by modest intrarater reliability and low interrater agreement. Digital grading is a promising evaluation method showing excellent intrarater reliability and correlation. Correlation for visual and digital grading was consistently modest, partly supporting the potential use of digital technology in dental anatomy grading.

3D and 2D marginal fit of pressed and CAD/CAM lithium disilicate crowns made from digital and conventional impressions.

PURPOSE: This in vitro study evaluated the 3D and 2D marginal fit of pressed and computer-aided-designed/computer-aided-manufactured (CAD/CAM) all-ceramic crowns made from digital and conventional impressions. MATERIALS AND METHODS: A dentoform tooth (#30) was prepared for an all-ceramic crown (master die). Thirty type IV definitive casts were made from 30 polyvinyl siloxane (PVS) impressions. Thirty resin models were produced from thirty Lava Chairside Oral Scanner impressions. Thirty crowns were pressed in lithium disilicate (IPS e.max Press; 15/impression technique). Thirty crowns were milled from lithium disilicate blocks (IPS e.max CAD; 15/impression technique) using the E4D scanner and milling engine. The master die and the intaglio of the crowns were digitized using a 3D laser coordinate measurement machine with accuracy of ±0.00898 mm. For each specimen a separate data set was created for the Qualify 2012 software. The digital master die and the digital intaglio of each crown were merged using best-fitting alignment. An area above the margin with 0.75 mm occlusal-gingival width circumferentially was defined. The 3D marginal fit of each specimen was an average of all 3D gap values on that area. For the 2D measurements, the marginal gap was measured at two standardized points (on the margin and at 0.75 mm above the margin), from standardized facial-lingual and mesial-distal digitized sections. One-way ANOVA with post hoc Tukey's honestly significant difference and two-way ANOVA tests were used, separately, for statistical analysis of the 3D and 2D marginal data (alpha = 0.05). RESULTS: One-way ANOVA revealed that both 3D and 2D mean marginal gap for group A: PVS impression/IPS e.max Press (0.048 mm ± 0.009 and 0.040 mm ± 0.009) were significantly smaller than those obtained from the other three groups (p < 0.0001), while no significant differences were found among groups B: PVS impression/IPS e.max CAD (0.088 mm ± 0.024 and 0.076 mm ± 0.023), C: digital impression/IPS e.max Press (0.089 mm ± 0.020 and 0.075 mm ± 0.015) and D: digital impression/IPS e.max CAD (0.084 mm ± 0.021 and 0.074 mm ± 0.026). The results of two-way ANOVA revealed a significant interaction between impression techniques and crown fabrication methods for both 3D and 2D measurements. CONCLUSIONS: The combination of PVS impression method and press fabrication technique produced the most accurate 3D and 2D marginal fits.

Fracture toughness of yttria-stabilized zirconia sintered in conventional and microwave ovens.

STATEMENT OF PROBLEM: The fabrication of zirconium dioxide (ZrO2) dental prosthetic substructures requires an extended sintering process (8 to 10 hours) in a conventional oven. Microwave sintering is a shorter process (2 hours) than conventional sintering. PURPOSE: The purpose of this study was to compare the fracture toughness of 3 mol % Y2O3-stabilized ZrO2 sintered in a conventional or microwave oven. MATERIAL AND METHODS: Partially sintered ZrO2 specimens from 3 manufacturers, KaVo, Lava 3M, and Crystal HS were milled (KaVo Everest engine) and randomly divided into 2 groups: conventional sintering and microwave sintering (n=16 per group). The specimens were sintered according to the manufacturers' recommendations and stored in artificial saliva for 10 days. Fracture toughness was determined by using a 4-point bend test, and load to fracture was recorded. Mean fracture toughness for each material was calculated. A 2-way ANOVA followed by the Tukey HDS post hoc test was used to assess the significance of sintering and material effects on fracture toughness, including an interaction between the 2 factors (α=.05). RESULTS: The 2-way ANOVA suggested a significant main effect for ZrO2 manufacturer (P<.001). The post hoc Tukey HSD test indicated that mean fracture toughness for the KaVo ZrO2 (5.85 MPa·m(1/2) ±1.29) was significantly higher than for Lava 3M (5.19 MPa·m(1/2) ±0.47) and Crystal HS (4.94 MPa·m(1/2) ±0.66) (P<.05) and no significant difference was observed between Lava 3M and Crystal HS (P>.05). The main effect of the sintering process (Conventional [5.30 MPa·m(1/2) ±1.00] or Microwave [5.36 MPa·m(1/2) ±0.92]) was not significant (P=.76), and there was no interaction between sintering and ZrO2 manufacturer (P=.91). CONCLUSIONS: Based on the results of this study, no statistically significant difference was observed in the fracture toughness of ZrO2 sintered in microwave or conventional ovens.

A model for overview of student learning: a matrix of educational outcomes versus methodologies.

A concise overview of an institution's aspirations for its students becomes increasingly elusive because dental education has evolving emphases on priorities like critical thinking and adapting to new technology. The purpose of this article is to offer a learner-oriented matrix that gives a focus for discussion and an overview of an institution's educational outcomes. On one axis of the matrix, common educational outcomes are listed: knowledge, technical skills, critical thinking, ethical and professional values, patient and practice management, and social responsibility awareness. On the other axis, methodologies are listed: definition, cultivation strategies, measures (summative/formative, objective/subjective), institutional coordination, and competency determination. By completing the matrix, an overview of the process by which students reach these outcomes emerges. Each institution would likely complete the matrix differently and, ideally, with active discussion. While the matrix can first be used to establish "Where are we now?" for an institution, it can also be a starting point for more extensive matrices and further discussion. Vertical and horizontal analyses of the matrix provide a unique lens for viewing the institution's learning environment.

Human perception of dental porcelain translucency correlated to spectrophotometric measurements.

PURPOSE: This study evaluated the relationship between instrumental measurements and subjective visual assessment of differences in dental porcelain translucency. MATERIALS AND METHODS: Unshaded feldspathic porcelain was used with controlled amounts of tin oxide to create two groups of 12-mm diameter disks with incremental changes in opacity. Contrast ratio (CR = Yb/Yw) was determined with a spectrophotometer, and used as a measure of porcelain translucency (Group A = 0.20 to 0.40; Group B = 0.6-0.8). Within each group, there were 14 specimens with 11 CRs. Three observer groups (first year dental students, residents, faculty with >10 years of shade matching experience) were recruited to assess the translucency between porcelain disks under two lighting conditions (reflected light, transmitted light). Each subject's ability to distinguish between specimens of differing translucency was determined. Descriptive statistics and three-way ANOVA followed by a post-hoc Tukey-Kramer test were used to evaluate the translucency perception threshold (TPT) of subjects (alpha= 0.05). RESULTS: The overall mean TPT (DeltaC) was 0.07, while 50% of the subjects could perceive a 0.06 CR difference between porcelain specimens. Three-way ANOVA revealed a significant difference in translucency perception among the observer groups (p < 0.0001), whereas the main effects for porcelain opacity (p= 0.3038) and lighting condition (p= 0.0645) were not significant, and no significant interactions were found. Post-hoc Tukey-Kramer test indicated that the mean TPT observed in the faculty group (DeltaC = 0.04) was significantly lower than those observed in student (DeltaC = 0.09) and resident groups (DeltaC = 0.08), while there was no significant difference between students and residents. CONCLUSIONS: The overall mean TPT of all subjects was 0.07, and 50% of the study population perceived a 0.06 CR difference in translucency. Increased shade matching experience (> or =10 years) significantly improved the ability to perceive differences in translucency; however, neither the viewing condition nor porcelain opacity affected the perceived translucency threshold.

Development of the curve of Spee.

INTRODUCTION: Ferdinand Graf von Spee is credited with characterizing human occlusal curvature viewed in the sagittal plane. This naturally occurring phenomenon has clinical importance in orthodontics and restorative dentistry, yet we have little understanding of when, how, or why it develops. The purpose of this study was to expand our understanding by examining the development of the curve of Spee longitudinally in a sample of untreated subjects with normal occlusion from the deciduous dentition to adulthood. METHODS: Records of 16 male and 17 female subjects from the Iowa Facial Growth Study were selected and examined. The depth of the curve of Spee was measured on their study models at 7 time points from ages 4 (deciduous dentition) to 26 (adult dentition) years. The Wilcoxon signed rank test was used to compare changes in the curve of Spee depth between time points. For each subject, the relative eruption of the mandibular teeth was measured from corresponding cephalometric radiographs, and its contribution to the developing curve of Spee was ascertained. RESULTS: In the deciduous dentition, the curve of Spee is minimal. At mean ages of 4.05 and 5.27 years, the average curve of Spee depths are 0.24 and 0.25 mm, respectively. With change to the transitional dentition, corresponding to the eruption of the mandibular permanent first molars and central incisors (mean age, 6.91 years), the curve of Spee depth increases significantly (P < 0.0001) to a mean maximum depth of 1.32 mm. The curve of Spee then remains essentially unchanged until eruption of the second molars (mean age, 12.38 years), when the depth increases (P < 0.0001) to a mean maximum depth of 2.17 mm. In the adolescent dentition (mean age, 16.21 years), the depth decreases slightly (P = 0.0009) to a mean maximum depth of 1.98 mm, and, in the adult dentition (mean age 26.98 years), the curve remains unchanged (P = 0.66), with a mean maximum depth of 2.02 mm. No significant differences in curve of Spee development were found between either the right and left sides of the mandibular arch or the sexes. Radiographic measurements of tooth eruption confirm that the greatest increases in the curve of Spee occur as the mandibular permanent incisors, first molars, or second molars erupt above the pre-existing occlusal plane. CONCLUSIONS: On average, the curve of Spee initially develops as a result of mandibular permanent first molar and incisor eruption. The curve of Spee maintains this depth until the mandibular permanent second molars erupt above the occlusal plane, when it again deepens. During the adolescent dentition stage, the curve depth decreases slightly and then remains relatively stable into early adulthood.

In vitro fracture resistance of endodontically treated central incisors with varying ferrule heights and configurations.

STATEMENT OF PROBLEM: The in vitro effectiveness of a uniform circumferential ferrule has been established in the literature; however, the effect of a nonuniform circumferential ferrule height on fracture resistance is unknown. PURPOSE: This in vitro study investigated the resistance to static loading of endodontically treated teeth with uniform and nonuniform ferrule configurations. MATERIAL AND METHODS: Fifty extracted intact maxillary human central incisors were randomly assigned to 1 of 5 groups: CRN, no root canal treatment (RCT), restored with a crown; RCT/CRN, no dowel/core, restored with a crown; 2 FRL, 2-mm ferrule, cast dowel/core and crown; 0.5/2 FRL, nonuniform ferrule (2 mm buccal and lingual, 0.5 mm proximal), cast dowel/core and crown; and 0 FRL, no ferrule, cast dowel/core and crown. The teeth were prepared to standardized specifications and stored for 72 hours in 100% humidity prior to testing. Testing was conducted with a universal testing machine with the application of a static load, and the load (N) at failure was recorded. Statistical analysis was performed with a 1-way analysis of variance and the Tukey Honestly Significant Difference test (alpha=.05). The mode of fracture was noted by visual inspection for all specimens. RESULTS: There was strong evidence of group differences in mean fracture strength ( P <.0001). Following adjustment for all pairwise group comparisons, it was found that the lack of a ferrule resulted in a significantly lower mean fracture strength (0 FRL: 264.93 +/- 78.33 N) relative to all other groups. The presence of a nonuniform (0.5 to 2-mm vertical height) ferrule (0.5/2 FRL: 426.64 +/- 88.33 N) resulted in a significant decrease ( P =.0001) in mean fracture strength when compared with the uniform 2-mm vertical ferrule (2 FRL: 587.23 +/- 110.25 N), the group without RCT (CRN: 583.67 +/- 86.09 N), and the RCT-treated tooth with a crown alone (CRN/RCT: 571.04 +/- 154.86 N). The predominant mode of failure was an oblique fracture extending from the lingual margin to the facial surface just below the insertion of the tooth into the acrylic resin. CONCLUSION: The results demonstrated that central incisors restored with cast dowel/core and crowns with a 2-mm uniform ferrule were more fracture resistant compared to central incisors with nonuniform (0.5 to 2 mm) ferrule heights. Both the 2-mm ferrule and nonuniform ferrule groups were more fracture resistant than the group that lacked a ferrule.

Interim restorations.

Interim restorations are a critical component of fixed prosthodontic treatment, biologically and biomechanically. Interim restoration serves an important diagnostic role as a functional and esthetic try-in and as a blueprint for the design of the definitive prosthesis. When selecting materials for any interim restoration, clinicians must consider physical properties, handling properties, patient acceptance, and material cost. Although no single material meets all the requirements and material classification alone of a given product is not a predictor of clinical performance, bis-acryl materials are typically best suited to single-unit restorations, and poly(methylmethacrylate) interim materials are generally ideal for multi-unit, complex, long-term, interim fixed prostheses. As with most dental procedures, the technique used for fabrication has a greater effect on the final result than the specific material chosen.

Relative translucency of six all-ceramic systems. Part I: core materials.

STATEMENT OF PROBLEM: All-ceramic restorations have been advocated for superior esthetics. Various materials have been used to improve ceramic core strength, but it is unclear whether they affect the opacity of all-ceramic systems. PURPOSE: This study compared the translucency of 6 all-ceramic system core materials at clinically appropriate thicknesses. MATERIALS AND METHODS: Disc specimens 13 mm in diameter and 0.49 +/- 0.01 mm in thickness were fabricated from the following materials (n = 5 per group): IPS Empress dentin, IPS Empress 2 dentin, In-Ceram Alumina core, In-Ceram Spinell core, In-Ceram Zirconia core, and Procera AllCeram core. Empress and Empress 2 dentin specimens also were fabricated and tested at a thickness of 0.77 +/- 0.02 mm (the manufacturer's recommended core thickness is 0.8 mm). A high-noble metal-ceramic alloy (Porc. 52 SF) served as the control, and Vitadur Alpha opaque dentin was used as a standard. Sample reflectance (ratio of the intensity of reflected light to that of the incident light) was measured with an integrating sphere attached to a spectrophotometer across the visible spectrum (380 to 700 nm); 0-degree illumination and diffuse viewing geometry were used. Contrast ratios were calculated from the luminous reflectance (Y) of the specimens with a black (Yb) and a white (Yw) backing to give Yb/Yw with CIE illuminant D65 and a 2-degree observer function (0.0 = transparent, 1.0 = opaque). One-way analysis of variance and Tukey's multiple-comparison test were used to analyze the data (P<.05). RESULTS: Contrast ratios in order of most translucent to most opaque were as follows: Vitadur Alpha 0.60 +/- 0.03, Empress (0.5 mm) 0.64 +/- 0.01, In-Ceram Spinell 0.67 +/- 0.02, Empress 2 (0.5 mm) 0.68 +/- 0.02, Empress (0.8 mm) 0.72 +/- 0.01, Procera 0.72 +/- 0.01, Empress 2 (0.8 mm) 0.74 +/- 0.01, In-Ceram Alumina 0.87 +/- 0.01, In-Ceram Zirconia 1.00 +/- 0.01, and 52 SF alloy 1.00 +/- 0.00. CONCLUSION: Within the limitations of this study, there was a range of ceramic core translucency at clinically relevant core thicknesses. In order of decreasing translucency, the ranges were Vitadur Alpha dentin (standard) > In-Ceram Spinell > Empress, Procera, Empress 2 > In-Ceram Alumina > In-Ceram Zirconia, 52 SF alloy.

Relative translucency of six all-ceramic systems. Part II: core and veneer materials.

UNLABELLED: STATEMENT OF PROBLEM All-ceramic core materials with various strengthening compositions have a range of translucencies. It is unknown whether translucency differs when all-ceramic materials are fabricated similarly to the clinical restoration with a veneered core material. PURPOSE: This study compared the translucency of 6 all-ceramic materials veneered and glazed at clinically appropriate thicknesses. MATERIALS AND METHODS: Core specimens (n = 5 per group) of Empress dentin, Empress 2 dentin, In-Ceram Alumina, In-Ceram Spinell, In-Ceram Zirconia, and Procera AllCeram were fabricated as described in Part I of this study and veneered with their corresponding dentin porcelain to a final thickness of 1.47 +/- 0.01 mm. These specimens were compared with veneered Vitadur Alpha opaque dentin (as a standard), a clear glass disc (positive control), and a high-noble metal-ceramic alloy (Porc. 52 SF) veneered with Vitadur Omega dentin (negative control). Specimen reflectance was measured with an integrating sphere attached to a spectrophotometer across the visible spectrum (380 to 700 nm); 0-degree illumination and diffuse viewing geometry were used. Measurements were repeated after a glazing cycle. Contrast ratios were calculated from the luminous reflectance (Y) of the specimens with a black (Yb) and a white backing (Yw) to give Yb/Yw with CIE illuminant D65 and a 2-degree observer function (0.0 = transparent, 1.0 = opaque). One-way analysis of variance and Tukey's multiple-comparison test were used to analyze the data (P<.05). RESULTS: Significant differences in contrast ratios were found among the ceramic systems tested when they were veneered (P<.0001) and after the glazing cycle (P<.0001). Significant changes in contrast ratios (P<.0001) also were identified when the veneered specimens were glazed. CONCLUSION: Within the limitations of this study, a range of translucency was identified in the veneered all-ceramic systems tested. Such variability may affect their ability to match natural teeth. The glazing cycle resulted in decreased opacity for all test materials except the completely opaque In-Ceram Zirconia and metal-ceramic specimens.

Relationship between crown placement and the survival of endodontically treated teeth.

STATEMENT OF PROBLEM: Crowns have been considered the restoration of choice for endodontically treated teeth, but their selection has been based primarily on anecdotal evidence. PURPOSE: This study tested the hypothesis that crown placement (coronal coverage) is associated with improved survival of endodontically treated teeth when preaccess, endodontic, and restorative factors are controlled. MATERIAL AND METHODS: A University of Iowa College of Dentistry treatment database was used to identify permanent teeth that had undergone initial obturation between July 1, 1985, and December 31, 1987. Study patients were restricted to persons with at least 1 dental visit in each 2-year interval from 1985 to 1996; a simple random sample of 280 patients (n = 400 teeth) was selected. Dental charts, radiographs, and computerized databases were examined to ascertain variables of interest and to verify study inclusion criteria. Kaplan-Meier survival estimates were generated for the 203 teeth that satisfied study inclusion criteria. Multivariate Cox proportional hazards regression models were developed, with standard errors adjusted to account for clustering of teeth within patients. RESULTS: When tooth type and radiographic evidence of caries at access were controlled, the final Cox model showed that endodontically treated teeth not crowned after obturation were lost at a 6.0 times greater rate than teeth crowned after obturation (95% confidence interval: 3.2 to 11.3). CONCLUSION: Within the limitations of this study, a strong association between crown placement and the survival of endodontically treated teeth was observed. These results may impact treatment planning if long-term tooth retention is the primary goal.