Cyclic contact fatigue behavior of baria-silicate glass-ceramics as a function of crystal aspect ratio.

Ceramic materials are potentially useful for dental applications because of their esthetic potential and biocompatibility. However, evidence of contact fatigue damage in ceramics raises considerable concern regarding its effect on the survival probability predicted for dental prostheses. To simulate intraoral conditions, Hertzian indentation loading with steel indenters was applied in this study to characterize the fatigue failure mechanisms of ceramic materials. Baria silicate glasses and glass-ceramics with different aspect ratios of crystals were selected because the glass and crystal phases have similar density, elastic modulus, and thermal expansion coefficients. Therefore, this system is a model ceramic for studying the effect of crystal geometry on contact cyclic fatigue failure. The subsequent flexural strength results show that the failure of materials with a low fracture toughness such as baria-silicate glass (0.7 MPa m1/2) and glass-ceramic with an aspect ratio of 3.6/1 (1.3 MPa m1/2) initiated from cone cracks developed during cyclic loading for 103 to 105 cycles. The mean strengths of baria-silicate glass and glass-ceramics with an aspect ratio of 3.6/1 decreased significantly as a result of the presence of a cone crack. Failures of baria-silicate glass-ceramics with an aspect ratio of 8.1/1 (Kc = 2.1 MPa m1/2) were initiated from surface flaws caused by either grinding or cyclic loading. The gradual decrease of fracture stress was observed in specimens with an aspect ratio of 8.1/1 after loading in air for 103 to 105 cycles. A reduction of approximately 50 % in fracture stress levels was found for specimens with an aspect ratio of 8.1/1 after loading for 105 cycles in deionized water. Thus, even though this glass-ceramic with an 8.1/1 crystal aspect ratio material is tougher than that with a 3.6/1 crystal aspect ratio, the fatigue damage induced by a large number of cycles is comparable. The mechanisms for cyclic fatigue crack propagation in baria-silicate glass-ceramics are similar to those observed under quasi-static loading conditions. An intergranular fracture path was observed in glass-ceramics with an aspect ratio of 3.6/1. For an aspect ratio of 8.1/1, a transgranular fracture mode was dominant.

Surface degradation of dental ceramics as a function of environmental pH.

We tested the hypotheses that glass-ceramic veneers and overglazes degrade by ion exchange in an acidic environment, and that they degrade by breakdown of the silica network in a basic environment. Disk specimens of glass-ceramic veneer and glaze were fabricated and immersed in pH 2, 7, or 10 buffer solutions, for 1, 3, 5, 10, 15, and 30 days. Each specimen was placed in a shaker bath containing de-ionized distilled water at 80°C. Concentrations of Al(3+), Ca(2+), Zn(2+), Li(2+), and Si(4+) were analyzed by means of inductively coupled plasma atomic emission spectrometry (ICP/AES). Statistical analyses were performed by factorial ANOVA. Significant differences occurred among leached ion concentrations as a function of material type, solution pH, and exposure time. A substantial release of Si occurred at pH 10 over time, leading to a breakdown of the glass phase. At pH 2, dissolution was controlled by an ionic exchange mechanism. We conclude that ceramic veneers and glazes may be susceptible to considerable degradation in low- and high-pH buffer solutions.

Enamel roughness and depth profile after phosphoric acid etching of healthy and fluorotic enamel.

BACKGROUND: Dental fluorosis requires aesthetic treatment to improve appearance and etching of enamel surfaces with phosphoric acid is a key step for adhesive restorations. The aim of this study was to evaluate surface roughness and a depth profile in healthy and fluorotic enamel before and after phosphoric acid etching at 15, 30 and 60 seconds. METHODS: One hundred and sixty enamel samples from third molars with no fluorosis to severe fluorosis were evaluated by atomic force microscopy. RESULTS: Healthy enamel showed a statistically significant difference (p < 0.05) between mean surface roughness at 15 seconds (180.3 nm), 30 seconds (260.9 nm) and 60 seconds (346.5 nm); depth profiles revealed a significant difference for the 60 second treatment (4240.2 nm). For mild fluorosis, there was a statistically significant difference (p < 0.05) between mean surface roughness for 30 second (307.8 nm) and 60 second (346.6 nm) treatments; differences in depth profiles were statistically significant at 15 seconds (2546.7 nm), 30 seconds (3884.2 nm) and 60 seconds (3612.1 nm). For moderate fluorosis, a statistically significant difference (p < 0.05) was observed for surface roughness for 30 second (324.5 nm) and 60 second (396.6 nm) treatments. CONCLUSIONS: Surface roughness and depth profile analyses revealed that the best etching results were obtained at 15 seconds for the no fluorosis and mild fluorosis groups, and at 30 seconds for the moderate fluorosis group. Increasing the etching time for severe fluorosis decreased surface roughness and the depth profile, which suggests less micromechanical enamel retention for adhesive bonding applications.

Fluoride and chlorhexidine release from filled resins.

Resin-based materials that release either fluoride or chlorhexidine have been formulated for inhibiting caries activity. It is not known if the two agents, when incorporated into one material, would interact and affect their release potential. We hypothesized that the ratio of fluoride to chlorhexidine incorporated into a resin, and the pH of the storage medium, will affect their releases from the material. The material investigated contained 23 wt% of filler, and the ratios of calcium fluoride to chlorhexidine diacetate were 8/2, 5/5, and 2/8. The release was conducted in pH 4, 5, and 6 acetate buffers. The results showed that release of either agent increased as the pH of the medium decreased. The presence of fluoride salt substantially reduced the chlorhexidine release, while the presence of a specific quantity of chlorhexidine significantly increased fluoride release. This interaction can be utilized to optimize the release of either agent for therapeutic purposes.

Which mechanical and physical testing methods are relevant for predicting the clinical performance of ceramic-based dental prostheses?

PURPOSE: The survival and performance of clinical prostheses with a ceramic component are probabilistic in nature. Only under very rare circumstances will all of the prostheses in a group exhibit either 100% successes or 100% failures over a period of 5 years or more. Prosthesis failure may be defined as any condition that leads to replacement. These conditions include secondary caries, irreversible pulpitis, excessive wear of opposing tooth surfaces, excessive erosion and roughening of the ceramic surface, ditching of the cement margin, unacceptable esthetics, cracking, chipping and fracture. A systematic review of the dental literature was performed to determine the extent to which the mechanical and physical properties of dental alloys and ceramics can predict the 5-year clinical performance of metal-ceramic and all-ceramic fixed dental prostheses (FDP) and to determine the associated quality of reported outcomes associated with these clinical studies. MATERIALS AND METHODS: The review was based on clinical research studies of 5 years or greater duration that were published in English dental journals between 1980 and 2006 using the following key words and MeSH terms. Our search strategy was as follows: Search 1: Partial fixed denture OR denture, partial, fixed OR denture, partial fixed OR dental porcelain OR metal ceramic alloys OR dental ceramic Search 2: Prosthesis failure OR dental restoration failure OR time factors OR survival analysis Search 3: Meta-analysis OR evaluation studies OR review OR clinical trial OR comparative study OR follow-up studies OR prospective studies OR clinical follow-up study OR clinical trial OR longitudinal studies Inclusion of searches 1, 2 and 3 and limits placed on the publication date starting on January 1, 1980, English language, and clinical studies involving humans resulted in a total of 684 articles. By restricting the clinical studies to 5 years or more in duration, the number was reduced to 193. By eliminating resin-bonded FDPs, cantilever designs, implant-supported prostheses, crowns, inlay- or onlay-supported prostheses, a total of 37 articles remained for detailed review. After excluding review articles and articles involving resin-bonded bridges, single-author clinical research articles, cantilever designs and implant-supported FDPs, 11 clinical research articles remained. For these articles, it was not possible to determine conclusively the probability of failure for three-unit FDPs compared with four-unit and larger prostheses or the location of the crowns and pontics. RESULTS: This systematic review of studies on ceramic-based FDPs confirms the results of previous studies that, in most cases, less than 15% of these prostheses were removed or were in need of replacement at 10 years. However, there was considerable variability in the number of parameters that were reported as well as the range of details on failures that occurred. In some studies, a standardized evaluation system was used in which USPHS or Ryge criteria were applied. However, there was also great uncertainty in the definition of failure with respect to repairable fractures and whether the identified causative factors were directly or indirectly associated with the replacement of the prostheses. CONCLUSIONS: This review indicates that there is no single in vitro test variable that can predict clinical performance in these prostheses. Based on these reviews, there is an urgent need to develop a comprehensive classification system for identifying clinical prosthesis failures, technical complications and biologic complications. Guidelines on the retrieval of fractured prostheses and/or impressions that capture the fracture surface details should also be developed. The predictive power of in vitro data can be increased by finite element stress analysis and computer programs such as the CARES/Life software (NASA Lewis Research Center, Cleveland, OH) that estimates the time-dependent nature of ceramic structure survival.

Influence of pH and oxygen-inhibited layer on fluoride release properties of fluoride sealant.

OBJECTIVES: This study tested the hypothesis that the oxygen-inhibited layer on a light-cured methacrylate based resin and the pH of the storage medium would increase significantly the initial fluoride release and long-term release rate from fluoride dental sealant. METHODS: Forty-eight discs (16-mm diameter x 1-mm thick) were made from FluroShield (<5 wt% NaF) and Helioseal F (<30 wt% fluorosilicate glass) sealants. For each sealant, 24 discs were cured through a Mylar strip that covered the surface and the remaining 24 discs were cured in air allowing formation of the oxygen-inhibited surface. Each specimen in the 24-disc groups was stored individually in 25-mL vials, and divided into four six-vial groups to receive 10 mL of pH4-pH7 (designation of pH 4-7) lactate buffer solutions. The buffer solutions were replaced periodically up to 121 days. The cumulative fluoride release over time was used to determine the coefficients for short-term and long-term release. RESULTS: Two-way ANOVA showed that the mean coefficient values for either sealant were significantly influenced by the curing condition (p<0.0001) and pH (p<0.0001), except for short-term release from NaF sealant. The duration of short-term release was much longer for the fluorosilicate glass sealant. CONCLUSIONS: Both pH and the source of fluoride source incorporated in the sealant play significant roles in fluoride release.

Apparent interfacial fracture toughness of resin/ceramic systems.

We suggest that the apparent interfacial fracture toughness (K(A)) may be estimated by fracture mechanics and fractography. This study tested the hypothesis that the K(A) of the adhesion zone of resin/ceramic systems is affected by the ceramic microstructure. Lithia disilicate-based (Empress2-E2) and leucite-based (Empress-E1) ceramics were surface-treated with hydrofluoric acid (HF) and/or silane (S), followed by an adhesive resin. Microtensile test specimens (n = 30; area of 1 +/- 0.01 mm(2)) were indented (9.8 N) at the interface and loaded to failure in tension. We used tensile strength (sigma) and the critical crack size (c) to calculate K(A) (K(A) = Ysigmac(1/2)) (Y = 1.65). ANOVA and Weibull analyses were used for statistical analyses. Mean K(A) (MPa.m(1/2)) values were: (E1HF) 0.26 +/- 0.06; (E1S) 0.23 +/- 0.06; (E1HFS) 0.30 +/- 0.06; (E2HF) 0.31 +/- 0.06; (E2S) 0.13 +/- 0.05; and (E2HFS) 0.41 +/- 0.07. All fractures originated from indentation sites. Estimation of interfacial toughness was feasible by fracture mechanics and fractography. The K(A) for the systems tested was affected by the ceramic microstructure and surface treatment.

Controlled release of chlorhexidine from UDMA-TEGDMA resin.

Chlorhexidine salts are available in various formulations for dental applications. This study tested the hypothesis that the release of chlorhexidine from a urethane dimethacrylate and triethylene glycol dimethacrylate resin system can be effectively controlled by the chlorhexidine diacetate content and pH. The filler concentrations were 9.1, 23.1, or 33.3 wt%, and the filled resins were exposed to pH 4 and pH 6 acetate buffers. The results showed that Fickian diffusion was the dominant release mechanism. The rates of release were significantly higher in pH 4 buffer, which was attributed to the increase of chlorhexidine diacetate solubility at lower pH. The higher level of filler loading reduced the degree of polymerization, leading to a greater loss of organic components and higher chlorhexidine release rates.

Fracture surface analysis of clinically failed fixed partial dentures.

Ceramic systems have limited long-term fracture resistance, especially when they are used in posterior areas or for fixed partial dentures. The objective of this study was to determine the site of crack initiation and the causes of fracture of clinically failed ceramic fixed partial dentures. Six Empress 2 lithia-disilicate (Li(2)O x 2SiO(2))-based veneered bridges and 7 experimental lithia-disilicate-based non-veneered ceramic bridges were retrieved and analyzed. Fractography and fracture mechanics methods were used to estimate the stresses at failure in 6 bridges (50%) whose fracture initiated from the occlusal surface of the connectors. Fracture of 1 non-veneered bridge (8%) initiated within the gingival surface of the connector. Three veneered bridges fractured within the veneer layers. Failure stresses of the all-core fixed partial dentures ranged from 107 to 161 MPa. Failure stresses of the veneered fixed partial dentures ranged from 19 to 68 MPa. We conclude that fracture initiation sites are controlled primarily by contact damage.

Effect of CaF2 content on rate of fluoride release from filled resins.

Information on the time-dependent release of fluoride from filled resins containing fluoride particles as a function of particle content and solution pH is limited. This study characterized the fluoride ion release from filled resins containing CaF2 particles as a function of filler content and pH. Urethane dimethacrylate and triethylene glycol dimethacrylate resins were used to make filled-resin disks containing 9.09, 23.08, or 33.33 mass% CaF2 filler. Fluoride ion release for the 9.09 mass% concentration was independent of pH. Increasing the filler content from 9.09 to 33.33 mass% increased the fluoride release rate in pH 4.0 buffer solution, because of greater surface degradation. Fluoride ion release from disks stored in pH 6.0 buffer solutions occurred mainly by diffusion from disk surfaces, while fluoride release from disks in pH 4.0 buffers was controlled by diffusion from disk surfaces and degeneration of the resin matrix, which exposed more CaF2 particle surface area.

Informatics systems to assess and apply clinical research on dental restorative materials.

Dental biomaterials are used clinically for one or more of the following purposes: to restore function, to enhance esthetics, and to prevent or arrest demineralization of tooth structure. Studies of the clinical performance of restorations and prostheses made from these materials have generally focused on quality assessment and survival statistics. Data from these studies should provide probabilities of specific treatment outcomes that are useful for practicing dentists. However, the utility of these data is limited by the lack of national and international standards for assessing these clinical outcomes. Standardized approaches toward clinical informatics and treatment-decision analysis are urgently needed to minimize the variability of clinical outcomes reported in publications associated with direct and indirect restorative materials used for dental restorations and prostheses.

Influence of connector design on fracture probability of ceramic fixed-partial dentures.

Fracture of ceramic fixed-partial dentures (FPDs) tends to occur in the connector area because of stress concentrations. The objective of this study was to test the hypothesis that the radius of curvature at the gingival embrasure of the FPD connector significantly affects the fracture resistance of three-unit FPDs. Two three-dimensional finite element models (FEMs), representing two FPD connector designs, were created in a manner corresponding to that described in a previous experimental study (Oh, 2002). We performed fractographic analysis and FEM analyses based on CARES (NASA) post-processing software to determine the crack initiation site as well as to predict the characteristic strength, the location of peak stress concentrations, and the risk-of-rupture intensities. A good correlation was found between the experimentally measured failure loads and those predicted by FEM simulation analyses. Fractography revealed fracture initiation at the gingival embrasure, which confirms the numerically predicted fracture initiation site. For the designs tested, the radius of curvature at the gingival embrasure strongly affects the fracture resistance of FPDs.

Clinical decision-making for coronal caries management in the permanent dentition.

Optimal conservative treatment decisions to prevent, arrest, and reverse tooth demineralization caused by caries require probability estimates on caries risk and treatment outcomes. This review is focused on the use of the best scientific evidence to recommend treatment strategies for management of coronal caries in permanent teeth as a function of caries risk. Evidence suggests that assigning therapeutic regimens to individuals according to their risk levels should yield a significantly greater probability of success and better cost effectiveness than applying identical treatments to all patients independent of risk. Depending on caries risk levels, treatment decisions based on risk can minimize unnecessary surgical intervention by incorporating the best evidence to prescribe treatment regimens for the use of fluoride-releasing agents, sealants, chlorhexidine, or combinations of these products.

Contrast ratio of veneering and core ceramics as a function of thickness.

PURPOSE: The recent development of several dental ceramic products has raised questions concerning the relative translucency potential of these materials. The objective of this study was to test the hypothesis that the contrast ratio of dental core and veneering ceramics is a linear function of ceramic thickness. MATERIALS AND METHODS: Four groups of disk-shaped core ceramic specimens and four groups of veneering ceramic specimens (15 mm in diameter and 0.70, 1.10, 1.25, or 1.50 mm in thickness) were prepared for analysis. Five disks were randomly assigned to each of the eight groups. Four core ceramics were selected for study: (1) tetrasilicic fluormica glass ceramic, (2) quadruple-chain silicate glass ceramic, (3) barium silicate glass ceramic, and (4) sintered alumina. The four veneering ceramics included two feldspathic body porcelains, one fine-grained veneering porcelain, and one ultralow-fusing porcelain. RESULTS: There were significant differences among the mean contrast ratio values of these materials. The most translucent group of the core materials was tetrasilicic fluormica glass ceramic, and the least translucent material was sintered alumina. The most translucent group among the veneering ceramics was one of the feldspathic ceramics (Ceramco), and the least translucent material for all thicknesses was the ultralow-fusing veneering ceramic (Duceram LFC). The mean contrast ratio values were significantly different at a thickness of 1.50 mm of the four core ceramic groups and among the four veneering ceramic groups. CONCLUSION: The results of this study indicate that the tetrasilicic fluormica glass ceramic is generally the most translucent core ceramic for thicknesses of 0.70, 1.10, and 1.25 mm, and Ceramco porcelain is the most translucent veneering ceramic. However, for a thickness of 1.50 mm, the quadruple-chain silicate glass ceramic was the most translucent core ceramic. The relationship between contrast ratio and thickness was linear for all ceramics except Vita VMK 68.

Marginal fit of alumina-and zirconia-based fixed partial dentures produced by a CAD/CAM system.

Clinical long-term success of all-ceramic dental restorations can be significantly influenced by marginal discrepancies. As a result, this in vitro study evaluated the marginal fit of alumina- and zirconia-based fixed partial dentures (FPDs) machined by the Precident DCS system. Different master steel models of three-, four- and five-unit posterior FPDs with an 0.8 mm chamfer preparation were produced. FPDs made of DC-Zirkon and In-Ceram Zirconia core ceramics were machined by the Precident DCS system. The marginal fit of the milled frameworks placed on the master steel models was determined by a replica technique using a light-body silicone to fill the discrepancies between crown and tooth and a heavy-body material to stabilize the light-body impression material. The impressions were poured into an epoxy resin material and each model was cross-sectioned with a low speed diamond saw to better visualize marginal discrepancies. The marginal fit of the FPDs was evaluated by scanning electron microscopy. The measurements of the marginal fit exhibited mean marginal discrepancies in a range between 60.5 and 74.0 microm, mean marginal gaps in a range from 42.9 to 46.3 microm, mean vertical discrepancies in a range from 20.9 to 48.0 microm and mean horizontal discrepancies in the range of 42.0 to 58.8 microm. Statistical data analysis was performed using the non-parametric test of Kruskal-Wallis and Mann-Whitney. The analysis revealed no significant differences (p>0.05) between the mean marginal gaps and vertical and horizontal discrepancies. However, for some FPDs the mean values of the marginal discrepancies were significantly different (p < or =0.05). The wide range of the measured values may be attributed to the complex geometrical design of long span FPDs and difficulties regarding the milling process of brittle ceramic materials. Based on the selection of 100 microm as the limit of clinical acceptability, the results of this study can conclude that the level of marginal fit for alumina- and zirconia-based FPDs achieved with the Precident DCS system meet the clinical requirements.

Is it time to change state and regional dental licensure board exams in response to evidence from caries research?

State and regional board exams represent the final gateway to dental licensure. One would expect that the requirements for licensure would reflect procedures that are beneficial to each patient's oral health and that are consistent with the teachings of most dental schools. We conducted an Internet survey to determine whether Class 2 tooth preparations based on caries lesions whose radiolucencies were confined to enamel were allowed for state and regional exams. Information obtained for 46 of the 50 states revealed that 33 of the states (72%) allowed teeth with either an E1 or E2 lesion to be restored. Seventeen of these states allowed teeth with an E1 lesion to be restored. Only 12 of the 46 states (26%) covered by these boards did not allow teeth with E1 or E2 lesions to be surgically treated. In contrast, a recent report indicates that only 30% of dental schools permit teeth with enamel lesions to be restored to satisfy clinical requirements and competencies.

Fracture resistance of all-ceramic and metal-ceramic inlays.

PURPOSE: Metal-ceramic inlay designs were developed to determine if the esthetic qualities of all-ceramic inlays could be duplicated and at the same time improve their strength and stability. The objectives of this study were to: (1) compare the fracture resistance of metal-ceramic inlays with that of all-ceramic inlays; (2) determine the correlation between the degree of preparation taper and fracture resistance; and (3) determine the correlation between marginal gap width and fracture resistance. MATERIALS AND METHODS: Inlay preparations were made on 60 Dentoform teeth, with 30 teeth allocated for metal-ceramic inlays and 30 teeth for all-ceramic inlays. Each group was further subdivided into 5-, 10-, and 20-degree taper preparations. Metal-ceramic inlays were fabricated using Goldtech Bio 2000 metal and Ceramco porcelain extending to the margin, while all-ceramic inlays were made from Empress II ceramic. Marginal gap widths were measured at six critical areas after fabrication. The load at failure was measured using an Instron Universal Testing Machine. RESULTS: The mean fracture load for all-ceramic inlays and metal-ceramic inlays at 5, 10, and 20 degrees was 70+/-40 N, 48+/-37 N, 33+/-7 N, and 40+/-23 N, 29+/-22 N, and 14+/-4 N, respectively. The mean gap width was 105 microm and 126 microm for all-ceramic and metal-ceramic inlays, respectively. CONCLUSION: The mean fracture load for Empress inlays was significantly higher than that for metal-ceramic inlays. Inlays with a 5-degree taper were significantly more fracture resistant than those with a 20-degree taper. There was no relation between marginal gap width and fracture resistance.

Structural reliability of alumina-, feldspar-, leucite-, mica- and zirconia-based ceramics.

OBJECTIVES: The objective of this study was to test the hypothesis that industrially manufactured ceramic materials, such as Cerec Mark II and Zirconia-TZP, have a smaller range of fracture strength variation and therefore greater structural reliability than laboratory-processed dental ceramic materials. METHODS: Thirty bar specimens per material were prepared and tested. The four-point bend test was used to determine the flexure strength of all ceramic materials. The fracture stress values were analyzed by Weibull analysis to determine the Weibull modulus values (m) and the 1 and 5% probabilities of failure. RESULTS: The mean strength and standard deviation values for these ceramics are as follows: (MPa+/-SD) were: Cerec Mark II, 86.3+/-4.3; Dicor, 70.3+/-12.2; In-Ceram Alumina, 429. 3+/-87.2; IPS Empress, 83.9+/-11.3; Vitadur Alpha Core, 131.0+/-9.5; Vitadur Alpha Dentin, 60.7+/-6.8; Vita VMK 68, 82.7+/-10.0; and Zirconia-TZP, 913.0+/-50.2. There was no statistically significant difference among the flexure strength of Cerec Mark II, Dicor, IPS Empress, Vitadur Alpha Dentin, and Vita VMK 68 ceramics (p>0.05). The highest Weibull moduli were associated with Cerec Mark II and Zirconia-TZP ceramics (23.6 and 18.4). Dicor glass-ceramic and In-Ceram Alumina had the lowest m values (5.5 and 5.7), whereas intermediate values were observed for IPS-Empress, Vita VMK 68, Vitadur Alpha Dentin and Vitadur Alpha Core ceramics (8.6, 8.9, 10.0 and 13.0, respectively). CONCLUSIONS: Except for In-Ceram Alumina, Vitadur Alpha and Zirconia-TZP core ceramics, most of the investigated ceramic materials fabricated under the condition of a dental laboratory were not stronger or more structurally reliable than Vita VMK 68 veneering porcelain. Only Cerec Mark II and Zirconia-TZP specimens, which were prepared from an industrially optimized ceramic material, exhibited m values greater than 18. Hence, we conclude that industrially prepared ceramics are more structurally reliable materials for dental applications although CAD-CAM procedures may induce surface and subsurface flaws that may adversely affect this property.

Minimal intervention dentistry--a review. FDI Commission Project 1-97.

The concept of minimal intervention dentistry has evolved as a consequence of our increased understanding of the caries process and the development of adhesive restorative materials. It is now recognised that demineralised but noncavitated enamel and dentine can be 'healed', and that the surgical approach to the treatment of a caries lesion along with 'extension for prevention' as proposed by G V Black is no longer tenable. This paper gives an overview of the concepts of minimal intervention dentistry, describes suggested techniques for a minimally invasive operative approach, and reviews clinical studies which have been carried out in this area.

Crack initiation modes in bilayered alumina/porcelain disks as a function of core/veneer thickness ratio and supporting substrate stiffness.

We hypothesize that the fracture resistance of alumina core/porcelain veneer disks increases and that crack initiation shifts from veneer to core as the core/veneer thickness ratio (t(C)/t(V)) increases from 0.5/1.0 to 1.3/0.2, or as the elastic modulus of the supporting substrate (E(S)) to which it is resin-bonded increases from 5.1 to 226 GPa. When supported by a low-modulus substrate, disks with low t(C)/t(V) ratios exhibited cracks in the veneer and within the core, while those with high t(C)/t(V) ratios demonstrated core cracks, but not veneer cracks. None of the disks supported by Ni-Cr alloy (E = 226 GPa) exhibited core cracks. These results support the hypothesis that the crack initiation site shifts as the t(C)/t(V) ratio increases, but the increase in E(S) did not affect the crack initiation site. This study suggests that the t(C)/t(V) ratio is the dominant factor that controls the failure initiation site in bilayered ceramic disks.