A Novel Etchant System for Orthodontic Bracket Bonding.

Orthodontic treatment is widely used to correct irregular teeth and/or jaw discrepancies to improve oral function and facial aesthetics. However, it is frequently associated with enamel damage that include chipping, demineralisation, and white spot formation. So far, current bonding systems that can maintain shear bond strengths (SBS) suitable for clinical performance are unable to limit enamel demineralisation, adhesive remnants and damage caused on removal of brackets after treatment. This study reports a novel "safe enamel etch" clinically viable procedure that was accomplished via application of novel etchant pastes developed with ß-tricalcium phosphate and monocalcium phosphate monohydrate powders mixed with citric acid (5 M) or phosphoric acid (37% PA) to yield BCA and BPA etchants respectively. Although enamel etched with clinically used PA gel yielded higher SBS than the BCA/BPA etchants, it exhibited greater adhesive remnants with evidence of enamel damage. In contrast, the experimental etchants resulted in unblemished enamel surfaces with zero or minimal adhesive residue and clinically acceptable SBS. Furthermore, the BPA etchant caused lower enamel decalcification with extensive calcium-phosphate precipitation. The study conclusively showed that BPA facilitated in vitro enamel adhesion without detrimental effects of the aggressive PA gel with potential for remineralisation and saving time at the post-debonding step.

Outside-the-(cavity-prep)-box thinking.

Direct placement restorative materials must interface with tooth structures that are often compromised by caries or trauma. The material must seal the interface while providing sufficient strength and wear resistance to assure function of the tooth for, ideally, the lifetime of the patient. Needed are direct restorative materials that are less technique-sensitive than current resin-based composite systems while having improved properties. The ideal material could be successfully used in areas of the world with limited infrastructure. Advances in our understanding of the interface between the restoration adhesive system and the stages of carious dentin can be used to promote remineralization. Application of fracture mechanics to adhesion at the tooth-restoration interface can provide insights for improvement. Research in polymer systems suggests alternatives to current composite resin matrix systems to overcome technique sensitivity, while advances in nano- and mesoparticle reinforcement and alignment in composite systems can increase material strength, toughness, and wear resistance, foreshadowing dental application.

The PBRN initiative: transforming new technologies to improve patient care.

The NIDCR-supported Practice-based Research Network initiative presents dentistry with an unprecedented opportunity by providing a pathway for modifying and advancing the profession. It encourages practitioner participation in the transfer of science into practice for the improvement of patient care. PBRNs vary in infrastructure and design, and sustaining themselves in the long term may involve clinical trial validation by regulatory agencies. This paper discusses the PBRN concept in general and uses the New York University College of Dentistry's Practitioners Engaged in Applied Research and Learning (PEARL) Network as a model to improve patient outcomes. The PEARL Network is structured to ensure generalizability of results, data integrity, and to provide an infrastructure in which scientists can address clinical practitioner research interests. PEARL evaluates new technologies, conducts comparative effectiveness research, participates in multidisciplinary clinical studies, helps evaluate alternative models of healthcare, educates and trains future clinical faculty for academic positions, expands continuing education to include "benchmarking" as a form of continuous feedback to practitioners, adds value to dental schools' educational programs, and collaborates with the oral health care and pharmaceutical industries and medical PBRNs to advance the dental profession and further the integration of dental research and practice into contemporary healthcare (NCT00867997, NCT01268605).

An assessment of the perceived benefits and challenges of participating in a practice-based research network.

BACKGROUND: A survey was conducted to describe the benefits of and challenges to practitioner participation in the Practitioners Engaged in Applied Research and Learning (PEARL) Network, a dental practice-based research network (PBRN). The results were compared with results from medical PBRNs across different tiers of participation (based on practitioner-investigators previous involvement with PEARL research protocols). METHODS: A 39-item web-based survey addressed the benefits of PBRN participation on three levels: individual/practitioner, practice (office), and community/professional. Participants were also asked to rate challenges to participation. RESULTS: A total of 153 of 216 PEARL practitioner-investigators participated, a response rate of 71%. The majority (70%) was male, with a median of 23 years in private practice. 'Means to stay informed of new developments in my profession' was considered a 'very important' benefit for nearly three-quarters of the sample (71%). 'Opportunity to improve clinical procedures' was considered as 'very important' by 73% of respondents. In terms of benefits related to the community and profession, 65% of respondents reported 'means to directly contribute to the evidence base of dental practice' as being 'very important'. 'Disruption in practice routine/clinical practice' was considered the most important challenge to participation. CONCLUSIONS: The benefits of and challenges to participation identified did not differ across tiers of participation and were similar to benefits identified by participants in medical PBRNs. The results of this study will help facilitate the design of future PBRN protocols to encourage greater participation by the profession. Results suggest that practitioners with similar interests could be recruited to collaborative studies between medicine and dentistry.

Reliability of reduced-thickness and thinly veneered lithium disilicate crowns.

The present investigation hypothesized that the reliability of reduced-thickness monolithic lithium disilicate crowns is high relative to that of veneered zirconia (Y-TZP) and comparable with that of metal ceramic (MCR) systems. CAD/CAM first mandibular molar full-crown preparations were produced with uniform thicknesses of either 1.0-mm or 2.0-mm occlusal and axial reduction, then replicated in composite for standard crown dies. Monolithic 1.0-mm (MON) and 2.0-mm CAD/CAM lithium disilicate crowns, the latter with a buccal thin veneer (BTV) of 0.5 mm, were fabricated and then sliding-contact-fatigued (step-stress method) until failure or suspension (n = 18/group). Crack evolution was followed, and fractography of post mortem specimens was performed and compared with that of clinical specimens. Use level probability Weibull calculation (use load = 1,200 N) showed interval overlaps between MON and BTV. There was no significant difference between the Weibull characteristic failure loads of MON and BTV (1,535 N [90% CI 1,354-1,740] and 1,609 N [90% CI 1,512-1,712], respectively), which were significantly higher than that of Y-TZP (370 N [90% CI 322-427]) and comparable with that of MCR (1,304 N [90% CI 1,203-1,414]), validating the study hypothesis.

Improving fatigue damage resistance of alumina through surface grading.

Porcelain-veneered alumina crown restorations often fail from bulk fracture resulting from radial cracks that initiate at the cementation surface with repeated flexure of the stiffer crown layers on the soft dentin support. We hypothesized that bulk fracture may be substantially mitigated by grading the elastic modulus at the crown surfaces. In this study, we fabricated graded structures by infiltrating glass into dense alumina plates, resulting in a diminished modulus at the surface layers. The plates were then bonded to polycarbonate substrates and subjected to fatigue loading in water. Tests were terminated when fracture occurred at the cementation tensile surface or at the fatigue endurance limit (1 million cycles). Infiltrated specimens showed a significant increase in fatigue fracture loads over non-infiltrated controls. Our results indicate that controlled elastic gradients at the surface could be highly beneficial in the design of fracture-resistant alumina crowns.

Performance of dental ceramics: challenges for improvements.

The clinical success of modern dental ceramics depends on an array of factors, ranging from initial physical properties of the material itself, to the fabrication and clinical procedures that inevitably damage these brittle materials, and the oral environment. Understanding the influence of these factors on clinical performance has engaged the dental, ceramics, and engineering communities alike. The objective of this review is to first summarize clinical, experimental, and analytic results reported in the recent literature. Additionally, it seeks to address how this new information adds insight into predictive test procedures and reveals challenges for future improvements.

Modified Y-TZP core design improves all-ceramic crown reliability.

This study tested the hypothesis that all-ceramic core-veneer system crown reliability is improved by modification of the core design. We modeled a tooth preparation by reducing the height of proximal walls by 1.5 mm and the occlusal surface by 2.0 mm. The CAD-based tooth preparation was replicated and positioned in a dental articulator for core and veneer fabrication. Standard (0.5 mm uniform thickness) and modified (2.5 mm height lingual and proximal cervical areas) core designs were produced, followed by the application of veneer porcelain for a total thickness of 1.5 mm. The crowns were cemented to 30-day-aged composite dies and were either single-load-to-failure or step-stress-accelerated fatigue-tested. Use of level probability plots showed significantly higher reliability for the modified core design group. The fatigue fracture modes were veneer chipping not exposing the core for the standard group, and exposing the veneer core interface for the modified group.

Reliability of metalloceramic and zirconia-based ceramic crowns.

Despite the increasing utilization of all-ceramic crown systems, their mechanical performance relative to that of metal ceramic restorations (MCR) has yet to be determined. This investigation tested the hypothesis that MCR present higher reliability over two Y-TZP all-ceramic crown systems under mouth-motion fatigue conditions. A CAD-based tooth preparation with the average dimensions of a mandibular first molar was used as a master die to fabricate all restorations. One 0.5-mm Pd-Ag and two Y-TZP system cores were veneered with 1.5 mm porcelain. Crowns were cemented onto aged (60 days in water) composite (Z100, 3M/ESPE) reproductions of the die. Mouth-motion fatigue was performed, and use level probability Weibull curves were determined. Failure modes of all systems included chipping or fracture of the porcelain veneer initiating at the indentation site. Fatigue was an acceleration factor for all-ceramic systems, but not for the MCR system. The latter presented significantly higher reliability under mouth-motion cyclic mechanical testing.

Damage and reliability of Y-TZP after cementation surface treatment.

Zirconia-based restorations are widely used in prosthetic dentistry, but their susceptibility to post-sintering cementation surface treatments remains controversial. We hypothesized that grinding (600-grit) and alumina abrasion (50 microm, 5 sec, 0.5 MPa) affect the damage modes and reliability of zirconia core material. Monolithic CAD/CAM-machined and sintered Y-TZP plates (0.5 mm thickness) were adhesively cemented to dentin-like composite substrates. Uni-axial mouth-motion cyclic contact was applied through a tungsten carbide spherical indenter (r = 3.18 mm). Results showed that zirconia core ceramic is vulnerable to lower surface radial fracture after grinding or alumina abrasion, while the as-received control chiefly fractured from load-application surface cone fracture. Significantly lower reliability of ground and alumina-abraded compared with the as-received zirconia core ceramic can be attributed to damage induced on the cementation surface. Clinical relevance concerning surface treatment protocols for zirconia framework materials prior to cementation is addressed.

Laboratory simulation of Y-TZP all-ceramic crown clinical failures.

Clinically, zirconia-supported all-ceramic restorations are failing by veneer-chipping without exposing the zirconia interface. We hypothesized that mouth motion step-stress-accelerated fatigue testing of standardized dental crowns would permit this previously unrecognized failure mode to be investigated. Using CAD software, we imported the average dimensions of a mandibular first molar crown and modeled tooth preparation. The CAD-based tooth preparation was rapid-prototyped as a die for fabrication of zirconia core porcelain-veneered crowns. Crowns were bonded to aged composite reproductions of the preparation and aged 14 days in water. Crowns were single-cycle-loaded to failure or mouth-motion step-stress- fatigue-tested. Finite element analysis indicated high stress levels below the load and at margins, in agreement with only single-cycle fracture origins. As hypothesized, the mouth motion sliding contact fatigue resulted in veneer chipping, reproducing clinical findings allowing for investigations into the underlying causes of such failures.

Fatigue testing of two porcelain-zirconia all-ceramic crown systems.

OBJECTIVE: To evaluate the mouth-motion step-stress fatigue behavior of two porcelain-zirconia all-ceramic crown systems. METHODS: The average dimensions of a mandibular first molar crown were imported into CAD software; a tooth preparation was modeled by reducing proximal walls by 1.5 mm and occlusal surface by 2.0 mm. The CAD-based tooth preparation was made by rapid prototyping and used as a master die to fabricate all-ceramic crowns with 1.0 mm porcelain veneered on 0.5 mm Y-TZP cores (LAVA veneer+LAVA frame, 3M/ESPE, and Vita veneer+CERCON frame, Dentsply). Crowns were cemented on aged (60 days in water) composite (Z100, 3M/ESPE) reproductions of the die. Three crowns from the LAVA group were subjected to single cycle load to failure for stress profile design; remainder subjected to step-stress mouth-motion fatigue (three step-stress profiles). All mechanical testing was performed by sliding a WC indenter of 6.25 mm diameter 0.7 mm lingually down the mesio-distal cusp. Master Weibull curves and reliability for missions of 50,000 cycles at 200 N load were calculated (Alta Pro 7, Reliasoft). RESULTS: Single load to failure showed fractures through the zirconia core. Reliability for a 200 N x 50K cycle mission was not significantly different between systems. In fatigue, failure occurred by formation of large chips within the veneer originating from the contact area without core exposure. CONCLUSIONS: LAVA and CERCON ceramic systems present similar fatigue behavior; fatigue loading of both systems reproduces clinically observed failure modes.

Fracture modes in human teeth.

The structural integrity of teeth under stress is vital to functional longevity. We tested the hypothesis that this integrity is limited by fracture of the enamel. Experiments were conducted on molar teeth, with a metal rod loaded onto individual cusps. Fracture during testing was tracked with a video camera. Two longitudinal modes of cracking were observed: median cracking from the contact zone, and margin cracking along side walls. Median cracks initiated from plastic damage at the contact site, at first growing slowly and then accelerating to the tooth margin. Margin cracks appeared to originate from the cemento-enamel junction, and traversed the tooth wall adjacent to the loaded cusp from the gingival to the occlusal surface. All cracks remained confined within the enamel shell up to about 550 N. At higher loads, additional crack modes--such as enamel chipping and delamination--began to manifest themselves, leading to more comprehensive failure of the tooth structure.

Removal of O-linked and N-linked oligosaccharides is required for optimum detection of NITEGE neoepitope on ADAMTS4-digested fetal aggrecans: implications for specific N-linked glycan-dependent aggrecanolysis at Glu373-Ala374.

OBJECTIVES: We have observed that Western blot analysis with an anti-G1 antibody detects G1-NITEGE product in a disintegrin and metalloprotease with thrombospondin motifs-4 (ADAMTS4)-digested fetal and mature human and bovine aggrecan, but the neoepitope-specific anti-NITEGE antibody only detects this product in digests of mature aggrecan. Our objective was to determine whether enzymatic removal of O- and/or N-linked oligosaccharides from the fetal products would enable detection of the NITEGE neoepitope with anti-NITEGE antibody. METHODS: Aggrecan was purified from fetal and mature human and bovine cartilage and digested with: (1) ADAMTS4, (2) ADAMTS4, sialidase II, and N-glycanase, (3) ADAMTS4, sialidase II, and O-glycanase, or (4) ADAMTS4, sialidase II, and both N- and O-glycanases. Western blot analysis was performed using anti-G1 and anti-NITEGE antibodies. RESULTS: When fetal G1-NITEGE products were treated with a combination of ADAMTS4, sialidase II, O-glycanase and N-glycanase, the resultant products migrated faster on sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and the NITEGE neoepitope was rendered detectable. CONCLUSIONS: It appears that the NITEGE neoepitope is blocked on Western blots by oligosaccharide structures present on Asn368 and Thr370 of fetal human and bovine aggrecans. Such masking structures do not appear to be present on mature aggrecans from these species. We suggest that when anti-NITEGE antibody is used in Western analysis, enzyme-linked immunosorbent assay (ELISA), fluorescence-activated cell sorting (FACS), and immunohistochemistry (IHC), removal of oligosaccharides with appropriate glycosidases may unmask reactivity that would otherwise go undetected. The implications of these findings for the much-studied effect of Asn368-linked keratan sulfate (KS)-based structures on ADAMTS4 and ADAMTS5 activity are discussed.

Laboratory and FEA evaluation of dentin-to-composite bonding as a function adhesive layer thickness.

OBJECTIVE: The aim of this study was to test the hypothesis that microtensile bond strength values are inversely proportional to dentin-to-composite adhesive layer thickness through laboratory mechanical testing and finite element analysis. METHOD: Eighteen noncarious third molars were obtained, and occlusal enamel removed perpendicular to the tooth long axis. Two different adhesive systems were utilized as follows (n=3): (1) application of a single layer of Single Bond (3M ESPE Co.) and Clearfil SE Bond (Kuraray Co.) following the manufacturer's directions; (2) application of one layer of both adhesive systems followed by one additional layer; (3) application of one layer of both adhesive systems followed by two additional layers. A 4mm build up was fabricated in increments on each tooth sample (Z 100 composite, 3M ESPE). Section measurements were performed and specimens were separated into three adhesive thickness groups per material (40, 40-80 and 80-120 microm) for microtensile testing. The bond strength data (MPa) were analyzed by one-way ANOVA and Tukey test. Maximum principal stresses (MPS) were determined through FEA for three different adhesive layer thicknesses (20, 50 and 100 microm). RESULTS: The bond strength data obtained for Single Bond at 0-40 microm presented significantly higher values compared to higher adhesive layer thickness groups. There were no statistical differences among bond strength values for all Clearfil SE Bond adhesive layer thicknesses. FEA modeling indicated that MPS increased as adhesive layer increased. The hypothesis was accepted for the Single Bond only. SIGNIFICANCE: Correspondence (not tested statistically) between microtensile laboratory testing and FEA model was only observed for Single Bond as increased adhesive layer thickness did not reduce Clearfil SE Bond strength.

Modeling of water absorption induced cracks in resin-based composite supported ceramic layer structures.

Cracking patterns in the top ceramic layers of the modeled dental multilayers with polymer foundation are observed when they are immersed in water. This article developed a model to understand this cracking mechanism. When water diffuses into the polymer foundation of dental restorations, the foundation will expand; as a result, the stress will build up in the top ceramic layer because of the bending and stretching. A finite element model based on this mechanism is built to predict the stress build-up and the slow crack growth in the top ceramic layers during the water absorption. Our simulations show that the stress build-up by this mechanism is high enough to cause the cracking in the top ceramic layers and the cracking patterns predicted by our model are well consistent with those observed in experiments on glass/epoxy/polymer multilayers. The model is then used to discuss the life prediction of different dental ceramics.

Sliding contact fatigue damage in layered ceramic structures.

Porcelain-veneered restorations often chip and fracture from repeated occlusal loading, making fatigue studies relevant. Most fatigue studies are limited to uni-axial loading without sliding motion. We hypothesized that bi-axial loading (contact-load-slide-liftoff, simulating a masticatory cycle), as compared with uni-axial loading, accelerates the fatigue of layered ceramics. Monolithic glass plates were epoxy-joined to polycarbonate substrates as a transparent model for an all-ceramic crown on dentin. Uni-and bi-axial cyclic contact was applied through a hard sphere in water, by means of a mouth-motion simulator apparatus. The uni-axial (contact-load-hold-liftoff) and traditional R-ratio fatigue (indenter never leaves the specimen surface) produced similar lifespans, while bi-axial fatigue was more severe. The accelerated crack growth rate in bi-axial fatigue is attributed to enhanced tensile stresses at the trailing edges of a moving indenter. Fracture mechanics descriptions for damage evolution in brittle materials loaded repeatedly with a sliding sphere are provided. Clinical relevance is addressed.

Fracture of porcelain-veneered structures in fatigue.

Porcelain-veneered crowns are widely used in modern dentistry, and their fracture remains problematic, especially in all-ceramic systems. We hypothesized that substructure properties have a significant effect on the longevity of porcelain-veneered crowns. Flat porcelain/metal or porcelain/ceramic structures were cemented to dentin-like composite, and a mouth-motion cyclic load of 200 N was delivered by means of a tungsten carbide spherical indenter (r = 3.18 mm), emulating occlusal loading on crowns supported by dentin. Findings indicated that porcelain on a low-hardness gold-infiltrated alloy was vulnerable to both occlusal surface contact damage and porcelain lower surface radial fracture, while porcelain on a higher-hardness palladium-silver alloy fractured chiefly from occlusal surface damage. The advantage of a high-modulus metal substructure was less pronounced. Fracture in the porcelain/zirconia system was limited to surface damage in the veneer layer, similar to that in the porcelain/palladium-silver system. Bulk fracture, observed in veneered alumina layers, was not found for zirconia.

Evaluation of a self-limiting concept in dentinal caries removal.

The mechanical removal of dentinal caries traditionally involves the use of tactile sensation and/or caries-indicating dyes. This study tested the hypothesis that self-limiting polymer burs are as effective as conventional carbide burs in creating substrates for dentin bonding. Carious dentin from extracted human molars was removed with carbide or polymer burs, with dental explorer hardness as the end-point for caries removal. Dentin substrates were bonded with etch-and-rinse or self-etch adhesives and prepared for microtensile bond testing and transmission electron microscopy. For each bur type, there was no difference in bond strength between adhesives. However, the polymer bur surface exhibited significantly lower bond strengths than the carbide bur, and both were lower than flat, non-carious dentin controls. TEM revealed areas of incompletely removed, denatured caries-infected dentin in the polymer bur specimens. These first-generation polymer burs might best be utilized for deep caries removal where pulpal exposure is a concern.