Clinical Performance of Filled/Nanofilled Versus Nonfilled Adhesive Systems in Noncarious Cervical Lesions: A Systematic Review and Meta-analysis.

CLINICAL RELEVANCE: The use of filled adhesive systems does not influence the clinical performance of the adhesive restoration in noncarious cervical lesions.

Fatigue resistance of all-ceramic fixed partial dentures - Fatigue tests and finite element analysis.

OBJECTIVE: To estimate the fatigue resistance of a new translucent zirconia material in comparison to lithium disilicate for 3-unit fixed partial dentures (FPDs). METHODS: Eighteen 3-unit FPDs (replacement of first upper molar) with a connector size of 4mm×4mm were dry milled with a five-axis milling machine (Zenotec Select, Wieland, Germany) using discs made of a new translucent zirconia material (IPS e.max ZirCAD MT, Ivoclar Vivadent). Another 9 FPDs with a reduced connector size (3mm×4mm) were milled. The zirconia FPDs were sintered at 1500°C. For a comparison, 9 FPDs were made of IPS e.max Press, using the same dimensions. These IPS e.max Press FPDs were ground from a wax disc (Wieland), invested and pressed at 920°C. All FPDs were glazed twice. The FPDs were adhesively luted to PMMA dies with Multilink Automix. Dynamic cyclic loading was carried out on the molar pontic using Dyna-Mess testing machines (Stolberg, Germany) with 2×106 cycles at 2Hz in water (37°C). Two specimens per group and load were subjected to decreasing load levels (at least 4) until the two specimens no longer showed any failures. Another third specimen was subjected to this load to confirm the result. All the specimens were evaluated under a stereo microscope (20× magnification). The number of cycles reached before observing a failure, and their dependence on the load and on the material, were modeled, using a Weibull model. This made it possible to estimate the fatigue resistance as the maximum load for which one would observe less than 1% failure after 2×106 cycles. In addition to the experimental study, Finite Element Modeling (FEM) simulations were conducted to predict the force to failure for IPS e.max ZirCAD MT and IPS e.max Press with a reduced cross-section of the connectors. RESULTS: The failure mode of the zirconia FPDs was mostly the fracture of the distal connector, whereas the failure mode of the lithium disilicate FPDs observed to be the fracture of the connectors or multiple cracks of the pontic. The fatigue resistance with 1% fracture probability was estimated to be 488N for the IPS e.max ZirCAD MT FPDs (453N for repeated test), 365N for IPS e.max ZirCAD MT FPDs with reduced connector size and 286N for the e.max Press FPDs. All three IPS e.max ZirCAD groups statistically performed significantly better than IPS e.max Press (p<0.001). On the other hand, no significant difference could be established between the two IPS e.max ZirCAD MT3 groups with a 4mm×4mm connector size (p>0.05). The allowable maximum principal stress (σmax) which did not lead to failure during fatigue testing for IPS e.max ZirCAD MT3 was calculated between 208MPa and 223MPa for FPDs with 4mm×4mm connectors for 2×106 cycles. This value could also be verified for the FPDs of the same material with 3mm×4mm connectors. On the other hand fatigue strength in terms of σmax at 2×106 cycles of IPS e.max Press was calculated to be between 78 and 90MPa. SIGNIFICANCE: The fatigue resistance of the translucent zirconia 3-unit FPDs was about 60-70% higher than that of the lithium disilicate 3-unit FPDs, which may justify their use for molar replacements, provided that a minimal connector size of 4mm×4mm is observed. Even with a limited number of specimens (n=9) per group it was possible to statistically differentiate between the tested groups.

Academy of Dental Materials guidance-Resin composites: Part II-Technique sensitivity (handling, polymerization, dimensional changes).

OBJECTIVE: The objective of this work, commissioned by the Academy of Dental Materials, was to review and critically appraise test methods to characterize properties related to critical issues for dental resin composites, including technique sensitivity and handling, polymerization, and dimensional stability, in order to provide specific guidance to investigators planning studies of these properties. METHODS: The properties that relate to each of the main clinical issues identified were ranked in terms of their priority for testing, and the specific test methods within each property were ranked. An attempt was made to focus on the tests and methods likely to be the most useful, applicable, and supported by the literature, and where possible, those showing a correlation with clinical outcomes. Certain methods are only briefly mentioned to be all-inclusive. When a standard test method exists, whether from dentistry or another field, this test has been identified. Specific examples from the literature are included for each test method. RESULTS: The properties for evaluating resin composites were ranked in the priority of measurement as follows: (1) porosity, radiopacity, sensitivity to ambient light, degree of conversion, polymerization kinetics, depth of cure, polymerization shrinkage and rate, polymerization stress, and hygroscopic expansion; (2) stickiness, slump resistance, and viscosity; and (3) thermal expansion. SIGNIFICANCE: The following guidance is meant to aid the researcher in choosing the most appropriate test methods when planning studies designed to assess certain key properties and characteristics of dental resin composites, specifically technique sensitivity and handling during placement, polymerization, and dimensional stability.

Academy of Dental Materials guidance-Resin composites: Part I-Mechanical properties.

OBJECTIVE: The objective of this project, which was initiated from the Academy of Dental Materials, was to review and critically appraise methods to determine fracture, deformation and wear resistance of dental resin composites, in an attempt to provide guidance for investigators endeavoring to study these properties for these materials. METHODS: Test methods have been ranked in the priority of the specific property being tested, as well as of the specific test methods for evaluating that property. Focus was placed on the tests that are considered to be of the highest priority in terms of being the most useful, applicable, supported by the literature, and which show a correlation with clinical findings. Others are mentioned briefly for the purpose of being inclusive. When a standard test method exists, including those used in other fields, these have been identified in the beginning of each section. Also, some examples from the resin composite literature are included for each test method. RESULTS: The properties for evaluating resin composites were ranked in the priority of measurement as following: (1) Strength, Elastic Modulus, Fracture toughness, Fatigue, Indentation Hardness, Wear-abrasion (third body) and Wear-attrition (contact/two body), (2) Toughness, Edge strength (chipping) and (3) Wear determined by toothbrush. SIGNIFICANCE: The following guidance is meant to aid the researcher in choosing the proper method to assess key properties of dental resin composites with regard to their fracture, deformation and wear resistance.

Using a chewing simulator for fatigue testing of metal ceramic crowns.

OBJECTIVE: Dynamic loading is a more important predictor for the clinical longevity of ceramic crowns than static loading. However, dynamic loading machines are costly and mostly have only one test station. The SD Mechatronik Chewing Simulator (formerly Willytec) may be a cost-effective alternative to evaluate the fatigue resistance of metal ceramic crowns. METHOD: Four metal ceramic materials were tested on lower first molar crowns: GC InitiaI, Creation (Willy Geller), IPS InLine (Ivoclar Vivadent) and the new low-fusion IPS Style Ceram (Ivoclar Vivadent). The ceramic material was manually layered on frames made of the nickel-chromium alloy 4all (Ivoclar Vivadent) by using a silicone mould. The crowns were adhesively luted to PMMA dies. Dynamic loading was carried out with a SD Mechatronik Chewing Simulator using additional bars with weights. A steel antagonist (Ø 4mm) with 40mm/s downward speed hit the disto-buccal cusp of the crown with minimal impulse while sliding for a distance of 0.7mm. The starting load was 250N. The forces at each load level had been verified with a 3D force sensor (Kistler). Four crowns per group and load were submitted to four decreasing load levels for 200,000 cycles with a resulting simulation frequency of 0.9Hz and simultaneous thermocycling (5°C/55°C) until all four crowns no longer showed chippings. Statistical analyses had been carried out using an exponential, a Weibull and a lognormal model. The fatigue resistance was defined as the maximal load for which one would observe less than 1% failure after 200,000 cycles. In addition to the fatigue testing of the molar crowns, simulations of finite element method (FEM) were conducted in order to investigate the influence of the mismatch of the thermal expansion coefficient (CTE) between the PMMA die and the molar crown on the fatigue resistance. RESULTS: The 3D-force measurements revealed that the summarised forces were very similar to the force of the dead weights that were put on the bars. The failure modes consisted of cracks and small and big chippings. Chi-square test and Gamma revealed no statistically significant differences between the four test materials in relation to the failure mode. At 250N all materials showed chippings within the ceramic or down to the metal frame, while at lower loads there were differences. The estimated fatigue resistance was 68N for GC Initial, 88N for Creation, 96N for IPS Style Ceram, and 105N for IPS InLine, when using a Weibull model and considering all possible events. Furthermore, FEM simulations revealed that the maximum values of the maximum principal stress were 90 MPa for the thermocycling and 225 MPa for the external load. CONCLUSION: The SD Mechatronik Chewing Simulator is an adequate and cost-effective tool to test layered PFM crowns for fatigue resistance. The test method and the chewing simulator can be used for ceramic on metal, ceramic on zirconia and monolithic ceramic materials.

Influence of cavity preparation, light-curing units, and composite filling on intrapulpal temperature increase in an in vitro tooth model.

This study examined the effect of both the tooth substance and restorative filling materials on the increase in pulp chamber temperature when using light-curing units with different power densities. The tip of a temperature sensor was positioned on the pulpal dentinal wall of the buccal side of a maxillary premolar. Metal tubes were inserted in the palatal and buccal root of the tooth, one for water inflow and the other for water outflow. Polyethylene tubes were connected from the metal tubes to a pump to control the flow rate. For the unprepared tooth group (group 1), the tooth was light-cured from the buccal side using two light-curing units (three curing modes): the VIP Junior (QTH, BISCO, Schaumburg, IL, USA) and the Bluephase LED light-curing units (two modes: LEDlow and LEDhigh; Ivoclar Vivadent, Schaan, Liechtenstein). The power densities of each light-curing unit for the LEDlow, QTH, and LEDhigh modes were 785 mW/cm(2), 891 mW/cm(2), and 1447 mW/cm(2), respectively. All light-curing units were activated for 60 seconds. For the prepared tooth group (group 2), a Class V cavity, 4.0 mm in width by 4.0 mm in height by 1.8 mm in depth in size, was prepared on the buccal surface of the same tooth for the temperature measurement. The light-curing and temperature measurements were performed using the same methods used in group 1. The cavity prepared in group 2 was filled with a resin composite (Tetric N Ceram A3 shade, Ivoclar Vivadent) (group 3) or a flowable composite (Tetric N Flow with A3 shade, Ivoclar Vivadent) (group 4). The light-curing and temperature measurements were performed for these groups using the same methods used for the other groups. The highest intrapulpal temperature (TMAX) was measured, and a comparison was conducted between the groups using two-way analysis of variance with a post hoc Tukey test at the 95% confidence level. The TMAX values were as follows: 38.4°C (group 1), 39.0°C (group 2), 39.8°C (group 3), and 40.3°C (group 4) for the LEDlow mode. For the QTH mode, the TMAX values were 40.1°C (group 1), 40.4°C (group 2), 40.9°C (group 3), and 41.4°C (group 4). For the LEDhigh mode, the TMAX values were 43.3°C (group 1), 44.5°C (group 2), 44.7°C (group 3), and 45.3°C (group 4). The statistical analysis revealed the following: the TMAX values were arranged by mode in the following manner: LEDlow < QTH < LEDhigh (p<0.05) and group 1 < group 2 ≤ group 3 ≤ group 4 (p<0.05).

Correlation of wear in vivo and six laboratory wear methods.

OBJECTIVE: We examined the correlation between clinical wear rates of restorative materials and enamel (TRAC Research Foundation, Provo, USA) and the results of six laboratory test methods (ACTA, Alabama (generalized, localized), Ivoclar (vertical, volumetric), Munich, OHSU (abrasion, attrition), Zurich). METHODS: Individual clinical wear data were available from clinical trials that were conducted by TRAC Research Foundation (formerly CRA) together with general practitioners. For each of the n=28 materials (21 composite resins for intra-coronal restorations [20 direct and 1 indirect], 5 resin materials for crowns, 1 amalgam, enamel) a minimum of 30 restorations had been placed in posterior teeth, mainly molars. The recall intervals were up to 5 years with the majority of materials (n=27) being monitored, however, only for up to 2 years. For the laboratory data, the databases MEDLINE and IADR abstracts were searched for wear data on materials which were also clinically tested by TRAC Research Foundation. Only those data for which the same test parameters (e.g. number of cycles, loading force, type of antagonist) had been published were included in the study. A different quantity of data was available for each laboratory method: Ivoclar (n=22), Zurich (n=20), Alabama (n=17), OHSU and ACTA (n=12), Munich (n=7). The clinical results were summed up in an index and a linear mixed model was fitted to the log wear measurements including the following factors: material, time (0.5, 1, 2 and 3 years), tooth (premolar/molar) and gender (male/female) as fixed effects, and patient as random effect. Relative ranks were created for each material and method; the same was performed with the clinical results. RESULTS: The mean age of the subjects was 40 (±12) years. The materials had been mostly applied in molars (81%) and 95% of the intracoronal restorations were Class II restorations. The mean number of individual wear data per material was 25 (range 14-42). The mean coefficient of variation of clinical wear data was 53%. The only significant correlation was reached by OHSU (abrasion) with a Spearman r of 0.86 (p=0.001). Zurich, ACTA, Alabama generalized wear and Ivoclar (volume) had correlation coefficients between 0.3 and 0.4. For Zurich, Alabama generalized wear and Munich, the correlation coefficient improved if only composites for direct use were taken into consideration. The combination of different laboratory methods did not significantly improve the correlation. SIGNIFICANCE: The clinical wear of composite resins is mainly dependent on differences between patients and less on the differences between materials. Laboratory methods to test conventional resins for wear are therefore less important, especially since most of them do not reflect the clinical wear.

Round robin test: wear of nine dental restorative materials in six different wear simulators - supplement to the round robin test of 2005.

OBJECTIVE: The purpose of the present study was to submit the same materials that were tested in the round robin wear test of 2002/2003 to the Alabama wear method. METHODS: Nine restorative materials, seven composites (belleGlass, Chromasit, Estenia, Heliomolar, SureFil, Targis, Tetric Ceram) an amalgam (Amalcap) and a ceramic (IPS Empress) have been submitted to the Alabama wear method for localized and generalized wear. The test centre did not know which brand they were testing. Both volumetric and vertical loss had been determined with an optical sensor. After completion of the wear test, the raw data were sent to IVOCLAR for further analysis. The statistical analysis of the data included logarithmic transformation of the data, the calculation of relative ranks of each material within each test centre, measures of agreement between methods, the discrimination power and coefficient of variation of each method as well as measures of the consistency and global performance for each material. RESULTS: Relative ranks of the materials varied tremendously between the test centres. When all materials were taken into account and the test methods compared with each other, only ACTA agreed reasonably well with two other methods, i.e. OHSU and ZURICH. On the other hand, MUNICH did not agree with the other methods at all. The ZURICH method showed the lowest discrimination power, ACTA, IVOCLAR and ALABAMA localized the highest. Material-wise, the best global performance was achieved by the leucite reinforced ceramic material Empress, which was clearly ahead of belleGlass, SureFil and Estenia. In contrast, Heliomolar, Tetric Ceram and especially Chromasit demonstrated a poor global performance. The best consistency was achieved by SureFil, Tetric Ceram and Chromasit, whereas the consistency of Amalcap and Heliomolar was poor. When comparing the laboratory data with clinical data, a significant agreement was found for the IVOCLAR and ALABAMA generalized wear method. SIGNIFICANCE: As the different wear simulator settings measure different wear mechanisms, it seems reasonable to combine at least two different wear settings to assess the wear resistance of a new material.

A new method to test the fracture probability of all-ceramic crowns with a dual-axis chewing simulator.

OBJECTIVES: The purpose of this study was to validate a new laboratory method to test all-ceramic systems with regard to the proportion of failures. METHODS: Sixteen standardized mandibular molar crowns consisting of two different materials (IPS Empress, IPS e.max Press) were adhesively luted on CAD/CAM milled PMMA abutments (first lower molar, circular chamfer). All crowns were loaded applying an eccentric force in a Willytec chewing simulator (steel stylus, Ø 2.4 mm, 2 mm lateral movement from fossa to cuspal tip) with stepwise increase of the load (3, 5, 9 kg, 100,000 cycles each, 0.8 Hz) and simultaneous thermocycling (5°C/55°C×417 per phase). Another four crowns of each material were subjected to force measurements with a 3D force sensor during dynamic loading of each loading phase using two different lateral movements (from fossa to cusp and vice versa). RESULTS: The cumulative forces for the three directions in space were much higher compared to the static load of the chewing simulator (maximal force at 3 kg 60 N, 5 kg 160 N, 9 kg 240 N). There was no statistically significant difference in the mean or maximal force between the two materials or two different lateral movements. During dynamic loading, no fractures occurred in the molar crowns made of IPS e.max Press, whereas 50% of the IPS Empress crowns showed failures (75% fractures and 25% chippings) (log-rank test p=0.002). Most of the Empress crowns fractured during the third loading phase (9 kg). CONCLUSIONS: The forces that the dead weights exerted during dynamic loading were 2-3 times higher than those during static loading. None of the lithium disilicate ceramic molar crowns fractured, whereas half of the leucite reinforced molar crowns failed during dynamic loading.

Crown pull-off test (crown retention test) to evaluate the bonding effectiveness of luting agents.

OBJECTIVE: The purpose of this review was to assess the influencing factors which affect laboratory tests that evaluate the effectiveness of luting agents on the retention of crowns in prepared dentin and - based on the results of the review - to propose a reasonable experimental setup. MATERIALS AND METHODS: The database MEDLINE was systematically searched for laboratory methods that evaluated the effectiveness of luting agents by pulling off crowns from prepared extracted teeth. RESULTS: Eighteen studies were included into the systematic review. The studies varied largely with regard to tooth type (molars, premolars), number of specimens (9-25), stump height (3-6mm), convergence angle (4.8-33 degrees ), standardization and measurement of preparation surface, seating force (25-200N), artificial ageing, crosshead speed for tensile force and statistical analysis. The coefficient of variation of the test results varied from 3% to 100%. The most important influencing factors for the crown dislodgement were stump height and convergence angle as well as the luting agent. Panavia and RelyX Unicem generally produced the highest values followed by glass ionomer and zinc phosphate cements. When pooling and normalizing the data, the mean difference between glass ionomer and resin-based materials as well as between glass ionomer and zinc phosphate cements was statistically significant (Wilcoxon, p<0.05). Seating force, roughness, type of cutting bur and use of a desensitizing agent had all a negligible effect on the test results. Artificial ageing like thermocycling had no influence with glass ionomer cements whereas for resin-based cements thermocycling and prolonged water storage generated similar a failures stress than thermocycling alone. The comparison with clinical results did not reveal conclusive evidence that the results of the laboratory methods completely reflect the results of prospective clinical trials in conjunction with single crowns and fixed dental prostheses. A reasonable experimental setup includes: at least 20 specimens per group, stump height 3mm, convergence angle 20 degrees , thermocycling of specimens (5000x), avoidance of shearing forces during dislodgement and failure probability statistics (Weibull). CONCLUSIONS: The results of pull-off tests with crowns that are cemented with luting agents varied largely and reflect only partially the results from clinical trials. The most influencing factors (standardized tooth preparation, avoidance of shearing stress during dislodgement of crown) had to be controlled to get meaningful results.

Surface deterioration of dental materials after simulated toothbrushing in relation to brushing time and load.

OBJECTIVES: (1) To evaluate the changes in surface roughness and gloss after simulated toothbrushing of 9 composite materials and 2 ceramic materials in relation to brushing time and load in vitro; (2) to assess the relationship between surface gloss and surface roughness. METHODS: Eight flat specimens of composite materials (microfilled: Adoro, Filtek Supreme, Heliomolar; microhybrid: Four Seasons, Tetric EvoCeram; hybrid: Compoglass F, Targis, Tetric Ceram; macrohybrid: Grandio), two ceramic materials (IPS d.SIGN and IPS Empress polished) were fabricated according to the manufacturer's instructions and optimally polished with up to 4000 grit SiC. The specimens were subjected to a toothbrushing (TB) simulation device (Willytec) with rotating movements, toothpaste slurry and at three different loads (100g/250g/350g). At hourly intervals from 1h to 10h TB, mean surface roughness Ra was measured with an optical sensor and the surface gloss (Gl) with a glossmeter. Statistical analysis was performed for log-transformed Ra data applying two-way ANOVA to evaluate the interaction between load and material and load and brushing time. RESULTS: There was a significant interaction between material and load as well as between load and brushing time (p<0.0001). The microhybrid and hybrid materials demonstrated more surface deterioration with higher loads, whereas with the microfilled resins Heliomolar and Adoro it was vice versa. For ceramic materials, no or little deterioration was observed over time and independent of the load. The ceramic materials and 3 of the composite materials (roughness) showed no further deterioration after 5h of toothbrushing. Mean surface gloss was the parameter which discriminated best between the materials, followed by mean surface roughness Ra. There was a strong correlation between surface gloss and surface roughness for all the materials except the ceramics. The evaluation of the deterioration curves of individual specimens revealed a more or less synchronous course suspecting hinting specific external conditions and not showing the true variability in relation to the tested material. SIGNIFICANCE: The surface roughness and gloss of dental materials changes with brushing time and load and thus results in different material rankings. Apart from Grandio, the hybrid composite resins were more prone to surface changes than microfilled composites. The deterioration potential of a composite material can be quickly assessed by measuring surface gloss. For this purpose, a brushing time of 10h (=72,000 strokes) is needed. In further comparative studies, specimens of different materials should be tested in one series to estimate the true variability.

Marginal adaptation in vitro and clinical outcome of Class V restorations.

OBJECTIVES: We examined the correlation between the quantitative margin analysis of two laboratory test methods (Berlin, Zurich) and the clinical outcome in Class V restorations. METHODS: Prospective clinical studies with an observation period of at least 18 months were searched in the literature, for which laboratory data were also available. The clinical outcome variables were retention loss, marginal discoloration, detectable margins and secondary caries. Forty-four clinical studies matched the inclusion criteria, including 34 adhesive systems for which laboratory data were also present. For both laboratory test methods and the clinical studies, an index was formulated to better compare the in vitro and in vivo results. Linear mixed models which included a random study effect were calculated. As most clinical data were available for 12 and 24 months, the main analysis was restricted to these recall intervals. RESULTS: The comparative analysis revealed a weak correlation between the clinical index and both in vitro indices. The correlation was statistically significant for the Berlin method but not for the Zurich method and only present if studies were compared which used the same composite in the in vitro and in vivo study. When defining specific cut-off values, the prognosis for the good clinical performance of an adhesive system based on in vitro results was 78% (Berlin) or 100% (Zurich). For poor performance it was 67% and 60%, respectively. No correlation was found between both in vitro methods. SIGNIFICANCE: The surrogate parameter "marginal adaptation" of restorations placed in extracted teeth has a mediocre value to predict the clinical performance of an adhesive system in cervical cavities. The composite is an important factor for a successful prediction. The comparison between in vitro/in vivo is sometimes hampered by the great variability of clinical results on the same adhesive system.

Fracture frequency of all-ceramic crowns during dynamic loading in a chewing simulator using different loading and luting protocols.

OBJECTIVE: The purpose of this laboratory study was to compare the frequency of failures (complete fractures or partial cracks) of molar crowns made of two different all-ceramic materials during dynamic loading in a chewing simulator, as well as the fracture load when subjected to static loading, in relation to different dynamic loading and luting protocols. METHODS: One hundred and forty-four molar crowns fabricated with IPS Empress or an experimental e.max Press material with high translucency (e.max Press Exp) were luted on CAD/CAM milled PMMA abutments (first lower molar, circular chamfer) either with Variolink or glass-ionomer cement (GIC). All crowns were loaded according to three different loading protocols (n=12 per group) and two force profiles (sinusoidal, rectangular) in a pneumatically driven chewing simulator with a steel stylus (Ø 8 mm) and they underwent simultaneous thermocycling (5 degrees C/55 degrees C). After each phase the crowns were evaluated with regard to fractures or cracks. After dynamic testing, the crowns that did not fail were subjected to compression loading until complete fracture in a universal testing machine (UTM). As control groups, unloaded crowns were also subjected to a UTM. Survival statistics with log-rank tests were applied for the results of the dynamic loading, while ANOVA with post hoc Tukey B was used for the fracture load results and two-way ANOVA was carried out for logarithmically transformed data. Weibull statistics were calculated for pooled fracture load data of the dynamically loaded and control groups. RESULTS: In the 144 IPS Empress crowns, complete fractures were observed in 9 crowns and partial cracks in another 3 crowns. When the data was pooled, a statistically significant increase in fractures occurred when the sinusoidal force profile was applied compared to a rectangular force profile (log-rank, p<0.05). No fractures occurred in the e.max Press Exp crowns. The two-way ANOVA showed that the type of luting protocol used had the most significant effect on the fracture load of both materials. In conjunction with Empress, however, the luting material influenced the variability twice as much as in e.max Press Exp. There was no statistically significant difference in the fracture load of GIC-luted e.max Press Exp crowns and that of the Variolink luted Empress crowns. The force profile had a significant effect on the fracture load only of the Empress crowns but not of the e.max Press Exp crowns. Weibull statistics revealed a higher scattering of the data of dynamically loaded crowns compared to that of the control groups. CONCLUSIONS: For testing all-ceramic materials, dynamic loading is indispensable to draw valid conclusions on clinical performance of all-ceramic molar crowns. A sinusoidal profile is advisable, while a gradual increase of the force amplitude does not significantly affect the results.

Wear of ceramic and antagonist--a systematic evaluation of influencing factors in vitro.

OBJECTIVE: (1) To systematically review the existing literature on in vitro assessments of antagonist wear of ceramic materials; (2) To systematically evaluate possible influencing factors on material and antagonist wear of ceramic specimens. METHODS: The database MEDLINE was searched with the terms "enamel," "wear" and "antagonist." The selected studies were analyzed with regard to wear parameters, type of antagonist and outcome. In the laboratory study, three ceramic materials were selected with different compositions and physical properties: IPS d.SIGN low-fusing metal ceramic, IPS Empress leucite ceramic, e.max Press lithium disilicate ceramic. These materials were subjected to the Ivoclar wear method (Willytec chewing simulator, 120,000cycles, 5kg weight) by systematically modifying the following variables which resulted in 36 tests with 8 specimens in each group: (1) configuration (flat, crown specimen), (2) surface treatment (polish, glaze), (3) type of antagonist (ceramic, two types of enamel stylus). Furthermore, the enamel styluses were cut to measure the enamel thickness and cusp width. Wear of both the material and the antagonist was quantified by scanning plaster replicas of the specimens with a laser scanner (etkon es1) and matching baseline and follow-up data with the Match 3D software (Willytec). The data were log-transformed to stabilize the variance and achieve near normality. To test the influence of specific test parameters, a four-way ANOVA with post hoc tests and Bonferroni correction was applied. RESULTS: The systematic review revealed 20 in vitro studies in which a material and the antagonist wear of the same material was examined. However, the results were inconsistent mainly due to the fact that the test parameters differed widely. Most studies used prepared enamel from extracted molars as the antagonist and flat polished ceramic specimens. The test chamber was filled with water and some sort of sliding movement was integrated in the wear generating process. However, there was a huge variation in relation to the applied force, the used force actuator, the number of cycles, and the frequency of cycles per time as well as the number of specimens. The results of the systematic laboratory tests revealed that the following factors strongly influence the wear: configuration (more material wear of flat versus crown specimens), surface treatment (more antagonist wear of glazed versus polished specimens), the antagonist system (more material wear and less antagonist wear for ceramic stylus versus enamel stylus), and enamel thickness (less wear for thicker enamel). Material wear was not very much different between the materials. However, e.max Press generally caused more antagonist wear than the other two materials, which were quite similar. However, the main influencing factors did not yield consistent results for all the subgroups and there was a huge variability of results within the subgroups especially in those groups that used enamel as antagonist. SIGNIFICANCE: As far as consistency and correlation with clinical studies is concerned, the set-up that consists of unprepared enamel of molar cusps against glazed crowns seems to be the most appropriate method to evaluate a ceramic material with regard to antagonist wear. However, due to the high variability of results large sample sizes are necessary to differentiate between materials, which calls the whole in vitro approach into question.

Recommendations for conducting controlled clinical studies of dental restorative materials.

About 35 years ago, Ryge provided a practical approach to evaluation of clinical performance of restorative materials. This systematic approach was soon universally accepted. While that methodology has served us well, a large number of scientific methodologies and more detailed questions have arisen that require more rigor. Current restorative materials have vastly improved clinical performance and any changes over time are not easily detected by the limited sensitivity of the Ryge criteria in short term clinical investigations. However, the clinical evaluation of restorations not only involves the restorative material per se but also different operative techniques. For instance, a composite resin may show good longevity data when applied in conventional cavities but not in modified operative approaches. Insensitivity, combined with the continually evolving and non-standard investigator modifications of the categories, scales, and reporting methods, has created a body of literature that is extremely difficult to meaningfully interpret. In many cases, the insensitivity of the original Ryge methods is misinterpreted as good clinical performance. While there are many good features of the original system, it is now time to move to a more contemporary one. The current review approaches this challenge in two ways: (1) a proposal for a modern clinical testing protocol for controlled clinical trials, and (2) an in-depth discussion of relevant clinical evaluation parameters, providing 84 references that are primarily related to issues or problems for clinical research trials. Together, these two parts offer a standard for the clinical testing of restorative materials/procedures and provide significant guidance for research teams in the design and conduct of contemporary clinical trials. Part 1 of the review considers the recruitment of subjects, restorations per subject, clinical events, validity versus bias, legal and regulatory aspects, rationales for clinical trial designs, guidelines for design, randomization, number of subjects, characteristics of participants, clinical assessment, standards and calibration, categories for assessment, criteria for evaluation, and supplemental documentation. Part 2 of the review considers categories of assessment for esthetic evaluation, functional assessment, biological responses to restorative materials, and statistical analysis of results. The overall review represents a considerable effort to include a range of clinical research interests over the past years. As part of the recognition of the importance of these suggestions, the review is being published simultaneously in identical form in both the "Journal of Adhesive Dentistry" and the "Clinical Oral Investigations." Additionally an extended abstract will be published in the "International Dental Journal" giving a link to the web full version. This should help to introduce these considerations more quickly to the scientific community.

How to qualify and validate wear simulation devices and methods.

The clinical significance of increased wear can mainly be attributed to impaired aesthetic appearance and/or functional restrictions. Little is known about the systemic effects of swallowed or inhaled worn particles that derive from restorations. As wear measurements in vivo are complicated and time-consuming, wear simulation devices and methods had been developed without, however, systematically looking at the factors that influence important wear parameters. Wear simulation devices shall simulate processes that occur in the oral cavity during mastication, namely force, force profile, contact time, sliding movement, clearance of worn material, etc. Different devices that use different force actuator principles are available. Those with the highest citation frequency in the literature are - in descending order - the Alabama, ACTA, OHSU, Zurich and MTS wear simulators. When following the FDA guidelines on good laboratory practice (GLP) only the expensive MTS wear simulator is a qualified machine to test wear in vitro; the force exerted by the hydraulic actuator is controlled and regulated during all movements of the stylus. All the other simulators lack control and regulation of force development during dynamic loading of the flat specimens. This may be an explanation for the high coefficient of variation of the results in some wear simulators (28-40%) and the poor reproducibility of wear results if dental databases are searched for wear results of specific dental materials (difference of 22-72% for the same material). As most of the machines are not qualifiable, wear methods applying the machine may have a sound concept but cannot be validated. Only with the MTS method have wear parameters and influencing factors been documented and verified. A good compromise with regard to costs, practicability and robustness is the Willytec chewing simulator, which uses weights as force actuator and step motors for vertical and lateral movements. The Ivoclar wear method run on the Willytec machine shows a mean coefficient of variation in vertical wear of 12%. Force measurements have revealed that in the beginning of the stylus/specimen contact phase the force impulse is 3-4 times higher during dynamic loading than during static loading. When correlating material properties to the wear results of 23 composite resins subjected to the Ivoclar method, some parameters could be identified and incorporated into a wear formula to predict wear with the Ivoclar method. A round robin test evaluating the wear of ten dental materials with five wear simulation methods showed that the results were not comparable, as all methods follow different wear testing concepts. All wear methods lack the evidence of their clinical relevance because prospective studies correlating in vitro with long-term in vivo results with identical materials are not available. For direct restorative materials, amalgam seems to be a realistic reference material. For indirect, namely crown and bridge materials, low strength ceramic is appropriate.

A comparison of three different methods for the quantification of the in vitro wear of dental materials.

OBJECTIVE: Different approaches are utilized to quantify the wear generated on flat specimens with a wear simulator. However, there are no systematic studies comparing different wear quantification methods with a series of materials that exhibit different wear rates. METHODS: Sixteen restorative materials, including 14 composites (BelleGlass, Chromasit, Estenia, Esthet-X, Four Seasons, Heliomolar RO, Heliomolar HB, Herculite XRV, InTen-S, Point 4, SureFil, Targis cured at 95 and 130 degrees C, Tetric Ceram) as well as an amalgam (Amalcap) and a ceramic (Empress) material, were subjected to attrition wear against standardized Empress antagonists in the Willytec wear simulator (120,000 cycles, 5 kg, 1.6 Hz). The volume and maximal vertical loss were quantified directly on the specimens with a profilometry device (Perthometer) and the FRT MicroProf optical sensor. After the fabrication of plaster replicas, the loss was also determined with a 3D laser scanning device. For the statistical analysis, the data were subjected to a logarithmic transformation. Intraclass correlation was calculated to measure the agreement among all three methods, while limits of agreement were used to compare one method against another. RESULTS: There was a very good agreement between all three quantification methods for both volume and vertical loss. The mechanical sensor measured consistently higher values compared to the optical sensors for the volume loss (correction factor 0.95), whereas for the vertical loss, consistently lower values were obtained (correction factor 1.17). However, the ranking of the materials was only marginally influenced by the quantification method. SIGNIFICANCE: All three sensors are suitable for the quantification of wear facets. Due to speed and simplicity, the laser sensor has greater advantages over the two other sensors.

Surface roughness and gloss of dental materials as a function of force and polishing time in vitro.

OBJECTIVES: The purpose of this study was (1) to analyze the influence of polishing time and press-on force on the surface gloss and roughness of dental materials by using a three-component rubber-based polishing system and to compare the results with those obtained in conjunction with an optimal polishing procedure and application of the specimens to a metal matrix, (2) to estimate the correlation between surface gloss and surface roughness. METHODS: Eight flat specimens were made of each dental material (Tetric Ceram [TC], Tetric EvoCeram [TE], Heliomolar [HM], Compoglass [CO] and Amalcap [AM]) and polished with 4000-grit SiC and a polishing liquid. Subsequently, the mean surface roughness (Ra) was measured with an optical sensor (FRT MicroProf) and the gloss (Gl) with a glossmeter (Novocurve). Prior to polishing the specimens with the polishing system, the surface was pre-roughened with 320-grit SiC paper and polishing was performed under water cooling at 10,000rpm, applying a controlled force of 2N. Each component of the Astropol system (F/P/HP) was used for 30s and Ra and Gl were measured at 5-second intervals. Other specimens of the same materials were polished with a controlled force of 4N or they were applied to a metal matrix and, subsequently, Ra and Gl were measured. To measure the influence of the polishing time on the surface gloss and roughness, repeated ANOVA with post-hoc paired t-tests was carried out in log-transformed Ra and gloss values. To estimate the correlation between Ra and Gl, the Spearman and Pearson correlation was calculated. RESULTS: (1) Surface gloss and surface roughness were time-dependent, showing the greatest improvement already after 5s of polishing with each of the polishing components, with the exception of AM, for which HP was not effective. The patterns of improvement varied considerably from material to material, but they were more consistent with regard to Gl than to Ra. (2) Ra was statistically significantly higher only in TC, TE and CO when 4N of force was applied instead of 2N. (3) Polishing the surface with a polishing machine resulted in a significantly better surface gloss in all materials. (4) After applying the specimens to a metal matrix, the surface roughness of all dental materials was significantly higher when compared to polished specimens except for TC. (5) Correlations between gloss and roughness were in general negative but they were higher for individual measurements compared to the differences between two consecutive measurements. SIGNIFICANCE: Both surface gloss and surface roughness were material-dependent and influenced by the polishing time and applied force. As gloss and roughness proved to be closely associated with each other, gloss assessment may be a sufficient method to screen materials with regard to their polishability.

Influence of the antagonist material on the wear of different composites using two different wear simulation methods.

OBJECTIVES: The aim of the study was to evaluate two ceramic materials as possible substitutes for enamel using two wear simulation methods, and to compare both methods with regard to the wear results for different materials. METHODS: Flat specimens (OHSU n=6, Ivoclar n=8) of one compomer and three composite materials (Dyract AP, Tetric Ceram, Z250, experimental composite) were fabricated and subjected to wear using two different wear testing methods and two pressable ceramic materials as stylus (Empress, experimental ceramic). For the OHSU method, enamel styli of the same dimensions as the ceramic stylus were fabricated additionally. Both wear testing methods differ with regard to loading force, lateral movement of stylus, stylus dimension, number of cycles, thermocycling and abrasive medium. In the OHSU method, the wear facets (mean vertical loss) were measured using a contact profilometer, while in the Ivoclar method (maximal vertical loss) a laser scanner was used for this purpose. Additionally, the vertical loss of the ceramic stylus was quantified for the Ivoclar method. The results obtained from each method were compared by ANOVA and Tukey's test (p<0.05). To compare both wear methods, the log-transformed data were used to establish relative ranks between material/stylus combinations and assessed by applying the Pearson correlation coefficient. RESULTS: The experimental ceramic material generated significantly less wear in Tetric Ceram and Z250 specimens compared to the Empress stylus in the Ivoclar method, whereas with the OHSU method, no difference between the two ceramic antagonists was found with regard to abrasion or attrition. The wear generated by the enamel stylus was not statistically different from that generated by the other two ceramic materials in the OHSU method. With the Ivoclar method, wear of the ceramic stylus was only statistically different when in contact with Tetric Ceram. There was a close correlation between the attrition wear of the OHSU and the wear of the Ivoclar method (Pearson coefficient 0.83, p=0.01). SIGNIFICANCE: Pressable ceramic materials can be used as a substitute for enamel in wear testing machines. However, material ranking may be affected by the type of ceramic material chosen. The attrition wear of the OHSU method was comparable with the wear generated with the Ivoclar method.