A comparative evaluation of fractural strength and marginal discrepancy of direct composite veneers using four different tooth preparation techniques: An in vitro study.

BACKGROUND: The direct composite veneers follow the concept of no preparation or minimal preparation that has developed an appropriate enamel bonding procedure. The composite veneers can be easily repaired and thus they are economically favorable. The long-term clinical performance of direct composite veneers depends on a number of factors, with fracture resistance and marginal adaptation being one of the significance. AIM AND OBJECTIVE: The aim of the present study was to evaluate the fractural strength and marginal discrepancy of direct composite veneers using four different tooth preparation techniques (window preparation, feather preparation, bevel preparation, and incisal overlap preparation). SETTINGS AND DESIGN: The present study is an in vitro study with the sample size of 75 participants. A total of 75 human extracted maxillary central incisors were collected and then divided into four experimental groups and one control group (n = 15 each). MATERIALS AND METHODS: A total of 75 human extracted maxillary central incisors were collected and then divided into four experimental groups and one control group (n = 15 each). Four tooth preparation techniques were performed followed by direct composite veneering. All the study samples were then splitted into two equal halves. One half of all the samples was subjected to a cell load from 0 N to 100 KN at a crosshead speed of 1 mm at 90° angulation using universal testing machine to evaluate the fractural strength. The other halves were sectioned longitudinally, and the samples were then subjected under the travelling microscope at ×200 magnification to measure the marginal discrepancy at cervical, middle, and incisal locations. STATISTICAL ANALYSIS: The data obtained were subjected to statistical analysis using SPSS Version 20.0. RESULTS: The fractural strength showed the maximum strength in Group V: Control group (273.33 ± 81.01), Group III: Bevel preparation (193.80 ± 66.59), Group IV: Incisal overlap preparation (188.93 ± 76.14), Group II: Feather preparation (160.33 ± 53.59), and least in Group I: Window preparation (147.74 ± 48.95). The marginal discrepancy showed maximum discrepancy in Group IV: Incisal overlap preparation (49.11 ± 6.33), Group II: Feather preparation (48.44 ± 6.01), Group III: Bevel preparation (46.67 ± 7.07), and least in Group I: Window preparation (45.33 ± 6.31). CONCLUSION: The fractural strength was maximum in Group V, followed by Group III, Group IV, Group II, and the least mean value score was found for the Group I, and the marginal discrepancy was maximum in Group IV, followed by Group II, Group III, and the least mean value score was found for the Group I.

Reabilitação estética anterior com laminados ultrafinos de cerâmica feldspática: um relato de caso / Anterior aesthetic rehabilitation with ultra-thin laminates of feldspathic ceramics. A case report

O presente caso clínico descreve um tratamento estético para corrigir a altura, o alinhamento e a presença de diastemas nos dentes ântero-superiores através do uso de laminados ultrafinos de cerâmica feldspática. A sequência operatória para a realização do tratamento estético anterior foi relatada, destacando as vantagens e desvantagens do material cerâmico selecionado. A cerâmica feldspática associada a técnicas minimamente invasivas e predominantemente aditivas contribuiu a obtenção de um excelente resultado estético. Além disso, o emprego do protocolo de adesão em esmalte assegurou longevidade e resistência ao conjunto dente-restauração. (AU)

The present case report describes an aesthetic treatment to correct the height, the alignment and the presence of diastema in the anterosuperior teeth through the use of ultrathin feldsphatic ceramic laminates. The operative worflow for performing the previous aesthetic treatment was reported, highlighting the advantages and disadvantages of the selected ceramic material. Feldsphatic ceramics associated with minimally invasive procedures and predominantly additive techniques contributed to an excellent aesthetic result. In addition, the bonding procedures protocol on enamel ensured longevity and resistance to the tooth-restoration set. (AU)

Fatigue strength of bilayered ceramics under cyclic loading as a function of core veneer thickness ratios.

STATEMENT OF PROBLEM: Minimal evidence is available concerning the appropriate thickness of each layer in bilayered ceramic systems. PURPOSE: The purpose of this in vitro study was to examine the effect of core-veneer thickness ratios on the fatigue strength of a bonded bilayered ceramic system. MATERIAL AND METHODS: Specimens of Ivoclar Porcelain System (IPS) e.max lithium disilicate were fabricated with core/veneer thicknesses of 0.5/1.0 mm, 0.75/0.75 mm, 1.0/0.5 mm, and 1.5/0.0 mm. All specimens were cemented to bases of a dentin-like material. Each specimen was cyclically loaded by a 2-mm-diameter G10 piston in water. Loads ranging from 10 N to the target load were applied at a frequency of 20 Hertz for 500,000 cycles. If cracked, the next specimen was cycled at a lower load; if not cracked, at a higher load (step size of 25 N). RESULTS: Mean and standard deviations of fatigue loads for the different core thicknesses were 0.5-mm core 610.94 N ±130.11; 0.75-mm core 600.0 N ±132.80; 1.0-mm core 537.50 N ±41.67; a Nd 1.5-mm core 501.14 N ±70.12. All veneered groups were significantly stronger than the full thickness group (ANOVA, P<.001; 95% post hoc). Cone cracking was observed only in the 2 thinner core groups (χ(2) test, P<.05), possibly indicating residual stresses. CONCLUSIONS: Results indicate that the addition of veneering porcelain to lithium disilicate cores increases the fatigue strength of the biceramic system.

In vitro evaluation of accuracy and precision of automated robotic tooth preparation system for porcelain laminate veneers.

STATEMENT OF PROBLEM: Controlling tooth reduction for porcelain laminate veneers (PLVs) in fractions of millimeters is challenging. PURPOSE: The purpose of this study was to assess an automated robotic tooth preparation system for PLVs for accuracy and precision compared with conventional freehand tooth preparation. MATERIAL AND METHODS: Twenty maxillary central incisor tooth models were divided into 2 groups. Ten were assigned to a veneer preparation with a robotic arm according to preoperative preparation design-specific guidelines (experimental group). Ten were assigned to conventional tooth preparation by a clinician (control group). Initially, all tooth models were scanned with a 3- dimensional (3D) laser scanner, and a tooth preparation for PLVs was designed on a 3D image. Each tooth model was attached to a typodont. For the experimental group, an electric high-speed handpiece with a 0.9-mm-diameter round diamond rotary cutting instrument was mounted on the robotic arm. The teeth were prepared automatically according to the designed image. For the control group, several diamond rotary cutting instruments were used to prepare the tooth models according to preoperative preparation design guidelines. All prepared tooth models were scanned. The preoperative preparation design image and scanned postoperative preparation images were superimposed. The dimensional difference between those 2 images was measured on the facial aspect, finish line, and incisal edge. Differences between the experimental and the control groups from the 3D design image were computed. Accuracy and precision were compared for all sites and separately for each tooth surface (facial, finish line, incisal). Statistical analyses were conducted with a permutation test for accuracy and with a modified robust Brown-Forsythe Levene-type test for precision (α=.05). RESULTS: For accuracy for all sites, the mean absolute deviation was 0.112 mm in the control group and 0.133 mm in the experimental group. No significant difference was found between the 2 (P=.15). For precision of all sites, the standard deviation was 0.141 mm in the control group and 0.185 mm in the experimental group. The standard deviation in the control group was significantly lower (P=.030). In terms of accuracy for the finish line, the control group was significantly less accurate (P=.038). For precision, the standard deviation in the control group was significantly higher at the finish line (P=.034). CONCLUSIONS: For the data from all sites, the experimental procedure was able to prepare the tooth model as accurately as the control, and the control procedure was able to prepare the tooth model with better precision. The experimental group showed better accuracy and precision at the finish line.

Shear bond strength of porcelain veneers rebonded to enamel.

In this laboratory research, shear bond strength (SBS) and mode of failure of veneers rebonded to enamel in shear compression were determined. Three groups (A, B, and C; n=10 each) of mounted molar teeth were finished flat using wet 600-grit silicon carbide paper, and 30 leucite-reinforced porcelain veneers (5.0 × 0.75 mm) were air abraded on the internal surface with 50 µm aluminum oxide, etched with 9.5% hydrofluoric acid, and silanated. The control group (A) veneer specimens were bonded to enamel after etching with 37% phosphoric acid using bonding resin and a dual cure resin composite cement. Groups B and C were prepared similarly to group A with the exception that a release agent was placed before the veneer was positioned on the prepared enamel surface and the resin cement was subsequently light activated. The debonded veneers from groups B and C were placed in a casting burnout oven and heated to 454°C/850°F for 10 minutes to completely carbonize the resin cement and stay below the glass transition temperature (Tg) of the leucite-reinforced porcelain. The recovered veneers were then prepared for bonding. The previously bonded enamel surfaces in group B were air abraded using 50 µm aluminum oxide followed by 37% phosphoric acid etching, while group C enamel specimens were acid etched only. All specimens were thermocycled between 5°C and 55°C for 2000 cycles using a 30-second dwell time and stored in 37°C deionized water for 2 weeks. SBS was determined at a crosshead speed of 1.0 mm/min. SBS results in MPa for the groups were (A) = 20.6±5.1, (B) = 18.1±5.5, and (C) = 17.2±6.1. One-way analysis of variance indicated that there were no significant interactions (α=0.05), and Tukey-Kramer post hoc comparisons (α=0.05) detected no significant pairwise differences. An adhesive mode of failure at the enamel interface was observed to occur more often in the experimental groups (B = 40%, C = 50%). Rebonding the veneers produced SBS values that were not significantly different from the control group. Also, no significant difference in SBS values were observed whether the debonded enamel surface was air abraded and acid etched or acid etched only.

CO2 Laser Glazing Treatment of a Veneering Porcelain: Effects on Porosity, Translucency, and Mechanical Properties.

This work tested CO2 laser as a glazing agent and investigated the effects of irradiation on the porosity, translucency, and mechanical properties of veneering porcelain. Sixty discs (diameter 3.5 × 2.0 mm) of veneering porcelain for Y-TZP frameworks (VM9, VITA Zahnfabrik) were sintered and had one of their faces mirror polished. The specimens were divided into six groups (n=10/group) according to surface treatment, as follows: no treatment-control; auto-glaze in furnace following manufacturer's instructions (G); and CO2 laser (45 or 50 W/cm(2)) applied for four or five minutes (L45/4, L45/5, L50/4, L50/5). Optical microscopy (Shimadzu, 100×) was conducted and the images were analyzed with Image J software for the determination of the following porosity parameters: area fraction, average size, and Feret diameter. The translucency parameter studied was masking ability, determined by color difference (ΔE) over black and white backgrounds (CM3370d, Konica Minolta). Microhardness and fracture toughness (indentation fracture) were measured with a Vickers indenter (HMV, Shimadzu). Contact atomic force microscopy (AFM) (50 × 50 µm(2), Nanoscope IIIA, Veeco) was performed at the center of one sample from each group, except in the case of L45/5. With regard to porosity and translucency parameters, auto-glazed and laser-irradiated specimens presented statistical similarity. The area fraction of the surface pores ranged between 2.4% and 5.4% for irradiated specimens. Group L50/5 presented higher microhardness when compared to the G group. The higher (1.1) and lower (0.8) values for fracture toughness (MPa.m(1/2)) were found in laser-irradiated groups (L50/4 and L45/4, respectively). AFM performed after laser treatment revealed changes in porcelain surface profile at a submicrometric scale, with the presence of elongated peaks and deep valleys.

Periapical status related to the quality of coronal restorations and root fillings in a Korean population.

INTRODUCTION: The purpose of this study was to assess the prevalence of apical periodontitis in root canal-treated teeth from the Korean population and to evaluate the relationship between the quality of root canal fillings and coronal restorations and the periapical status of these teeth. METHODS: Full-mouth periapical radiographs at the Dental Hospital of Yonsei University, Seoul, South Korea, were examined. A total of 1030 endodontically treated teeth restored with full veneer crown-type restorations were evaluated by 2 independent examiners. Teeth were classified as healthy or diseased according to the periapical status. The quality of endodontic treatment and coronal restorations were also classified via radiographic and clinical evaluation. The data were analyzed using the chi-square test and logistic regression. RESULTS: Forty-one percent of all endodontically treated teeth were classified as diseased. Approximately 35.6% of the teeth had endodontic treatments that were rated as adequate. The diseased teeth rate for cases with adequate endodontic treatment was 24.5%, which was significantly lower when compared with teeth with inadequate endodontic treatment (49.9%). The number of teeth with adequate coronal restorations was 706 (68.5%). Teeth with adequate coronal restorations had a significantly decreased prevalence of diseased teeth (34.7%) compared with teeth with inadequate coronal restorations (54.3%). Teeth with both adequate root fillings and restorations showed a significantly better outcome (82.3%) than the others, and teeth with both inadequate root fillings and restorations showed a significantly worse outcome (41.2%) than the others. CONCLUSIONS: Data from this Korean population showed a relatively high prevalence of apical periodontitis. The quality of endodontic treatment and coronal restorations were of equal importance and were strong independent predictors of the periapical status.

In vitro chipping behaviour of all-ceramic crowns with a zirconia framework and feldspathic veneering: comparison of CAD/CAM-produced veneer with manually layered veneer.

The purpose of this in vitro study was to assess the breaking load of zirconia-based crowns veneered with either CAD/CAM-produced or manually layered feldspathic ceramic. Thirty-two identical zirconia frameworks (Sirona inCoris ZI, mono L F1), 0·6 mm thick with an anatomically shaped occlusal area, were constructed (Sirona inLab 3.80). Sixteen of the crowns were then veneered by the use of CAD/CAM-fabricated feldspathic ceramic (CEREC Bloc, Sirona) and 16 by the use of hand-layered ceramic. The CAD/CAM-manufactured veneer was attached to the frameworks by the use of Panavia 2.0 (Kuraray). Half of the specimens were loaded until failure without artificial ageing; the other half of the specimens underwent thermal cycling and cyclic loading (1·2 million chewing cycles, force magnitude F(max) = 108 N) before the assessment of the ultimate load. To investigate the new technique further, finite element (FE) computations were conducted on the basis of the original geometry. Statistical assessment was made by the use of non-parametric tests. Initial breaking load was significantly higher in the hand-layered group than in the CAD/CAM group (mean: 1165·86 N versus 395·45 N). During chewing simulation, however, 87·5% (7/8) of the crowns in the hand-layered group failed, whereas no crown in the CAD/CAM group failed. The CAD/CAM-produced veneer was significantly less sensitive to ageing than the hand-layered veneer.

Effect of veneering technique on the fracture resistance of zirconia fixed dental prostheses.

To compare the fracture resistance of zirconia 3-unit posterior fixed dental prostheses (FDPs) frameworks veneered with different veneering materials and techniques before and after artificial ageing. Forty-eight zirconia 3-unit FDPs, representing a missing first molar, were adhesively cemented on human teeth. The zirconia frameworks were randomly distributed according to the veneering materials and techniques into three groups, each containing 16 samples: group LV (layering technique/Vintage ZR), group LZ (layering technique/ZIROX) and group PP (CAD/CAM and press-over techniques/PressXZr). Half of each group was artificially aged through dynamic loading and thermocycling to simulate 5 years of clinical service. Afterwards, all specimens were tested for fracture resistance using compressive load. An analysis of variance (anova) was used to assess the effect of veneering ceramic and artificial ageing on fracture resistance (P < 0·05). Except for one minor cohesive chipping in group LV1, all specimens survived artificial ageing. The mean fracture resistance values (in Newton) of different non-aged (± s.d.)/aged (± s.d.) groups were as follows: LV0 2034 (± 401)/LV1 1625 (± 291); LZ0 2373 (± 718)/LZ1 1769 (± 136); and PP0 1959 (± 453)/PP1 1897 (± 329). Artificial ageing significantly reduced the fracture resistance in groups veneered with the layering technique (P < 0·05), whereas no significant effect was found in specimens veneered with the CAD/CAM and press-over techniques. All tested systems have the potential to withstand occlusal forces applied in the posterior region. The combination of the CAD/CAM and press-over techniques for the veneering process improved the overall stability after artificial ageing, relative to the layering technique.

Clinical performance of porcelain laminate veneers: outcomes of the aesthetic pre-evaluative temporary (APT) technique.

This article evaluates the long-term clinical performance of porcelain laminate veneers bonded to teeth prepared with the use of an additive mock-up and aesthetic pre-evaluative temporary (APT) technique over a 12-year period. Sixty-six patients were restored with 580 porcelain laminate veneers. The technique, used for diagnosis, esthetic design, tooth preparation, and provisional restoration fabrication, was based on the APT protocol. The influence of several factors on the durability of veneers was analyzed according to pre- and postoperative parameters. With utilization of the APT restoration, over 80% of tooth preparations were confined to the dental enamel. Over 12 years, 42 laminate veneers failed, but when the preparations were limited to the enamel, the failure rate resulting from debonding and microleakage decreased to 0%. Porcelain laminate veneers presented a successful clinical performance in terms of marginal adaptation, discoloration, gingival recession, secondary caries, postoperative sensitivity, and satisfaction with restoration shade at the end of 12 years. The APT technique facilitated diagnosis, communication, and preparation, providing predictability for the restorative treatment. Limiting the preparation depth to the enamel surface significantly increases the performance of porcelain laminate veneers.

Shear bond strengths between alumina-toughened zirconia cores and veneering ceramics and their susceptibility to aging.

OBJECTIVE: To evaluate the shear bond strength (SBS) between alumina-toughened zirconia (ATZ) cores and veneering ceramics, investigate the effect of aging in artificial saliva on SBS and compare it with that of yttria-stabilized tetragonal zirconia polycrystals(Y-TZP). METHODS: Bars of ATZ and Y-TZP were layered with veneering ceramics in accordance to the recommendation of the manufacturer. Half of each group (n = 10) was aged at 134 °C (under 2 bar pressure) in an autoclave for 48 h. Subsequently, all specimens were subjected to shear force in a universal testing machine. The interface and fractured surface of the specimens were evaluated using scanning electron microscopy and X-ray energy dispersive spectroscopy. RESULTS: The initial mean SBS values in MPa±SD were 28.9±8.0 for ATZ and 26.2±7.6 for Y-TZP. After aging, the mean SBS values for ATZ and Y-TZP were 22.9±4.9 MPa and 22.8±6.9 MPa, respectively. Neither the differences between the SBS values of the ATZ and Y-TZP groups nor the influence of aging on all groups were statistically significant. CONCLUSIONS: The SBS between the ATZ core and the veneering ceramics was not affected by aging. The SBS of ATZ to veneering ceramics was not significantly different compared with that of Y-TZP.

Survival and complications of zirconia-based fixed dental prostheses: a systematic review.

STATEMENT OF PROBLEM: Evidence is limited on the efficacy of zirconia-based fixed dental prostheses. PURPOSE: The purpose of this systemic review was to assess zirconia-based FDPs in terms of survival and complications. MATERIAL AND METHODS: Searches performed in PubMed databases were enriched by hand searches to identify suitable publications. The keywords used were: "zirconia" and "fixed dental prosthesis," "zirconia" and "crown," "zirconia" and "fixed partial denture" and "humans," "zirconia" and "crown" and "humans," "crown" and "all-ceramics," and "fixed partial denture" and "all-ceramics". Titles and abstracts were read to identify literature that fulfilled the inclusion criteria. Only peer reviewed clinical studies published in the English language from January 1999 through June 2011 were included. RESULTS: Twelve clinical studies based on zirconia, framework design, and porcelain veneering technique met the inclusion criteria. Of the studies identified, 1 was a randomized clinical study with 3-year follow-up results; the others were cohort prospective studies. Clinical complications included chipping of veneering porcelain, abutment failure, and framework fracture. One study investigated pressed ceramics as the veneering material and found no chipping of veneering porcelain after 3 years. CONCLUSIONS: Short term clinical data suggest that zirconia-based fixed dental prostheses may serve as an alternative to metal ceramic fixed dental prostheses in the anterior and posterior dentition.

Clinical long-term evaluation and failure characteristics of 1,335 all-ceramic restorations.

PURPOSE: The aim of this clinical retrospective study was to evaluate the clinical quality, estimated survival rate, and failure analysis of different all-ceramic restorations in a long-term analysis of up to 20 years. MATERIALS AND METHODS: Different all-ceramic restorations (crowns [n = 470], veneers [n = 318], onlays [n = 213], and inlays ]n = 334[) were placed in 302 patients (120 men, 182 women) between 1987 and 2009 at Medical University Innsbruck, Innsbruck, Austria. Clinical examination was performed during patients' regularly scheduled maintenance appointments. Esthetic match, porcelain surface, marginal discoloration, and integrity were evaluated following modified California Dental Association/Ryge criteria. Number of restoration failures and reasons for failure were recorded. The study population included 106 (35.1%) individuals diagnosed with bruxism. The success rate was determined using Kaplan-Meier survival analysis. RESULTS: The mean observation time was 102 ± 60 months. Ninety-five failures were recorded. The main reason for failure was fracture of the ceramic (33.68%). The estimated survival rate was 97.3% after 5 years, 93.5% at 10 years, and 78.5% at 20 years. Nonvital teeth showed a significantly higher risk of failure (P < .0001). There was a 2.3-times greater risk of failure associated with existing parafunction (bruxism, P = .0045). Cementation using Variolink showed significantly fewer failures than Optec Cement (P = .0217) and Dual Cement (P = .0099). No significant differences were found for type of restoration and distribution in the mouth. CONCLUSION: All-ceramic restorations offer a predictable and successful restoration with an estimated survival probability of 93.5% over 10 years. Significantly increased failure rates are associated with bruxism, nonvital teeth, and specific cementation agents.

Clinical performance of porcelain laminate veneers for up to 20 years.

PURPOSE: The aim of this clinical retrospective study was to evaluate the clinical quality, success rate, and estimated survival rate of anterior veneers made of silicate glass-ceramic in a long-term analysis of up to 20 years. MATERIALS AND METHODS: Anterior teeth in the maxillae and mandibles of 84 patients (38 men, 46 women) were restored with 318 porcelain veneer restorations between 1987 and 2009 at the Medical University Innsbruck, Innsbruck, Austria. Clinical examination was performed during patients' regularly scheduled maintenance appointments. Esthetic match, porcelain surface, marginal discoloration, and integrity were evaluated following modified California Dental Association/Ryge criteria. Veneer failures and reasons for failure were recorded. The study population included 42 (50.0%) patients diagnosed with bruxism and 23 (27.38%) smokers. The success rate was determined using Kaplan-Meier survival analysis. RESULTS: The mean observation time was 118 ± 63 months. Twenty-nine failures (absolute: 82.76%, relative: 17.24%) were recorded. The main reason for failure was fracture of the ceramic (44.83%). The estimated survival rate was 94.4% after 5 years, 93.5% at 10 years, and 82.93% at 20 years. Nonvital teeth showed a significantly higher failure risk (P = .0012). There was a 7.7-times greater risk of failure associated with existing parafunction (bruxism, P = .0004). Marginal discoloration was significantly greater in smokers (P ⋜ .01). CONCLUSION: Porcelain laminate veneers offer a predictable and successful restoration with an estimated survival probability of 93.5% over 10 years. Significantly increased failure rates were associated with bruxism and nonvital teeth, and marginal discoloration was worse in patients who smoked.

Standardizing failure, success, and survival decisions in clinical studies of ceramic and metal-ceramic fixed dental prostheses.

UNLABELLED: The recent increase in reports from clinical studies of ceramic chipping has raised the question of which criteria should constitute success or failure of total-ceramic prostheses. Terminologies such as minor chipping [1], partial chipping, technical complications [2,3], and biological complications have crept into the dental terminology and they have complicated our classification of success and failure of these crown and bridge restorations. Some journals have permitted the reporting of fractures as "complications" and they are not necessarily classified as failures in the study. One study has attempted to classify chipping fractures according to their severity and subsequent treatment [4]. This is a promising approach to resolve the challenges to the classification of chipping fracture. The term 'chipping fracture' is more descriptive than 'chipping' since the latter term tends to imply an event of minor consequence. Two types of statistics are reported routinely in these studies, i.e., percent success, which is a measure of restorations that survive without any adverse effects, and percent survival, which is a measure of all restorations that survive even though they may have exhibited chipping fracture or they may have been repaired. Why has this scenario occurred? One possible explanation is that many of these types of fractures are very small and do not affect function or esthetics. Another reason is that corporate sponsors prefer to use the term chipping since it does not connote failure in the sense that the term fracture does. In any event, we need to be more precise in our scientific observations of fracture and classifications of the various types of fracture including details on the location of fracture and the prosthesis design configuration. Because of the lack of standardized methods for describing chipping fractures, materials scientists are unable to properly analyze the effect of material properties and design factors on the time-dependent survival probability of ceramic fixed dental prostheses (FDPs). Based on the review of clinical trials and systematic reviews of these trials, the present study was designed to develop guidelines for classifying the functional performance, success, survival, and susceptibility to chipping fracture, and subsequent treatment of ceramic and metal-ceramic restorations. OBJECTIVE: To develop comprehensive descriptive guidelines and a clinical reporting form to assist dental scientists in their analyses of chipping fracture behavior of metal-ceramic and all-ceramic prostheses with particular emphasis on veneered-zirconia restorations. These guidelines are required to optimize the recording of fracture features that can be used to differentiate ceramic chipping fracture from bulk fracture and to assist dentists in identifying subsequent treatment that may minimize the need to replace affected restorations. A recording form for clinical fracture observations must be sufficiently clear and complete so that dental health professionals can translate the most relevant information in a context that allows their patients to fully understand the potential risks and benefits of treatment with ceramic restorations. It should clearly allow a clinician to determine whether or not a ceramic fracture constitutes a failure, which requires replacement of the prosthesis, or whether the fracture surface is relatively small or located in a nonfunctional area, i.e., one that is not contribute to occlusion, esthetics, proximal contacts, or food impaction. To accomplish this task, a review of the relevant publications of clinical trials was necessary to identify the variability in reporting of fracture events. The reviews were focused on clinical research studies of zirconia-based FDPs and PFM FDPs, which had been monitored through recall exams for three years or more. These reports and systematic reviews of all relevant publications were published in English dental journals between 2004 and 2010.The primary focus in this review was on the susceptibility to chipping fracture or bulk fracture of veneered zirconia-based fixed dental prostheses (FDPs) and metal-ceramic FDPs, which are also referred to in this paper as porcelain-fused-to-metal (PFM) FDPs.

Testing a multistage rating scale for clinical evaluation of all-ceramic surfaces.

PURPOSE: This study tested the applicability of a multistage rating scale based on modified California Dental Association (CDA) criteria and the original criteria of the CDA for surface evaluation of all-ceramic restorations with the use of dental stone replicas, photographs, and scanning electron microscopy (SEM). MATERIALS AND METHODS: Two examiners clinically evaluated 105 all-ceramic restoration units in the posterior region after a mean observation period of 42.2 months; the examiners employed the CDA criteria and a detailed six-stage rating scale. In addition, standardized photographs and gypsum stone and epoxy replicas based on impressions were analyzed blindly using the same rating scales and examiners. SEM images of gold-coated epoxy replicas enabled indirect ceramic surface evaluation, serving as the gold standard to control indirect evaluation and clinical findings. The Cohen kappa was applied to test for concordance; intraclass correlations and Spearman rank correlations were calculated. RESULTS: Statistically significant rating correlations of the clinical situation, photographs, and stone replicas with the SEM photographs were generated from both evaluation systems. With the use of the multistage rating scale, the highest rating correlation was found for stone replica-SEM (r = 0.61, P < .001), and the lowest for clinical photography-SEM (r = 0.5, P < .001). CONCLUSIONS: A multistage rating scale based on modified CDA criteria is reliable for precise assessment of in vivo ceramic surface alterations. Stone replicas were found to be better-suited than photographs for the assessment of all-ceramic surface alterations and confirmation of clinical ratings.

Porcelain veneering of titanium--clinical and technical aspects.

Gold and other alloys have long been used for the production of crowns and bridges as replacements for damaged or lost teeth. However, doubts have arisen on the suitability of using these materials for dental restorations, as gold has also shown a capacity to cause side-effects such as allergic reactions. This is especially valid for alloys, which during the last decades have been used as porcelain-fused-to metal restorations. This fact has led to an interest in using titanium instead of these alloys. Trials to use titanium for this purpose were initiated in Japan in the early 1980s. Titanium as an unalloyed metal differs in two aspects from the above named alloys: it has a phase transformation at 882 degrees C, which changes its outer and inner properties, and it has an expansion that lies between that of the porcelain types available on the market at the time. In Japan a technique for casting titanium was developed, where the after-treatment of the casting was elaborate, to re-establish the original properties of titanium. The porcelain developed for veneering had shortcomings as the rendering produced a rough surface and non satisfactory esthetics. In Sweden a new concept was introduced in 1989. Here the processing of titanium was performed by industrial methods such as milling, spark erosion and laser welding. The idea behind this was to avoid phase transformation. During the 1990s a number of porcelain products were launched and a vast number of both laboratory and clinical studies were performed and published, with varying results. In the first study of this thesis a prospective clinical trial was performed at a public dental health clinic in Sweden. Twenty-five patients were provided with 40 copings of pure titanium, which were veneered with porcelain. After 2 years 36 of these crowns were evaluated and the patients were also interviewed regarding problems such as shooting pains or difficulties in cleaning around the teeth that were crowned. This evaluation showed generally unchanged values for color, form, surface and fit. Regarding surfaces, one porcelain fracture was registered (3%). The patient responses were positive and no case of sensitivity was reported after 2 years, but in 3 cases food impaction was reported. The second study is a systematic review of published articles on bond strength between titanium and porcelain. The review made comparisons of bond strength using three-point bending tests between different porcelain bonds to different alloys and to titanium, between different brands of porcelain and titanium, with porcelain following various types of processing of the titanium surface, with different compositions of the porcelain and with different firing conditions. Generally it could be seen that with this type of test (three-point bending) the bond strength between porcelain and titanium was lower than with alloys. It was also seen that there are differences in bond strengths between different brands of porcelain, that processing the titanium surface and composition of the porcelain affected bond strength, and that firing conditions were also important. The third study was performed with the intention of examining the firing accuracy of different types of dental furnaces and to investigate how maintenance and quality control is performed at Swedish dental laboratories. Since titanium porcelain is fired at a temperature which is 200 degrees C below that used for most conventional alloys, there are specific demands on the furnaces used. The optimum firing temperature is judged to be 750 degrees C for porcelain veneering of titanium, according to published studies. In this study the real firing temperature at the holding period of 1 minute was recorded by a thermo-element connected to a digital temperature measurement apparatus. The accuracy of tested furnaces demonstrated a wide variation, and in almost all cases the real temperature was higher than the temperature indicated by the furnace display; in some cases this was very much higher than the temperature displayed. This means a risk for an unwanted augmentation of the oxide layer on the titanium, which could fracture on loading. Regarding maintenance and quality control, interviews performed at 62 laboratories revealed that most of these did not attain the standards expected and claimed. The fourth study was performed with the intention of studying how the bond strength between titanium and porcelain is affected by a temperature increase of 30 degrees C, performed with two firing concepts for titanium porcelain and examined by three-point bending tests. The fractured surfaces were also analyzed with SEM and EDX. These two concepts for titanium porcelain differ in that one has an oxide firing of the titanium metal as the first firing step, while the other is fired with a bonding agent as the first step in the firing procedure. Furthermore, half of the test bodies were aged by thermo-cycling. This study has shown that a moderate elevation in the firing temperature does not affect the bond strength in this case. Comparing bond strengths between the two different firing concepts, three-point bending tests showed that the test bodies that had undergone an oxidation firing had significantly higher bond strengths in all but one situation. These results were contradicted by the SEM and EDX analysis. These showed that with oxidation firing the fractures occurred in the brittle (and probably thickened) oxide layer of the titanium, while the fractures occurred in the well integrated interface with titanium oxide and porcelain components when firing without oxidation. The reasons for these contradictory results might be that oxidation firing changed the ductility of the titanium, creating a higher stiffness which could better withstand the deflection of the specimens created during the three-point bending tests. For the same reason it might also be irrelevant to test bond strength between porcelain and metals with differing properties. Considering these results and the results from other studies, the validity of the current test standard for metal-ceramic bond strengths may be questioned.

Quantification of the esthetics of dentists' before and after photographs.

PURPOSE: The purpose of this study was to measure dentists' before and after restorative treatment photographs to identify four metrics to describe the esthetic improvement: (a) central incisor width-to-height ratio; (b) central-to-lateral incisor width ratio; (c) lateral incisor-to-canine width ratio; and (d) lateral incisor percentage offset. MATERIALS AND METHODS: Internet searches for "before after" and "veneers" and "prosthodontic" were used to obtain 198 before and after photographs of patient treatments showing the restoration of the six maxillary anterior teeth with porcelain veneers, crowns or a combination. The four metrics were measured using Adobe Photoshop. Groups were compared with repeated measures ANOVA followed by a post hoc Tukey-Kramer test with the variables of "Before or After Treatment"; "Treatment Type" (veneers, crowns or a combination) and "General Dentist or Prosthodontist". RESULTS: Mean central incisor width-to-height ratio was 91.7% before treatment, 80.8% after; mean central-to-lateral incisor width ratios were 69.9% and 64.7%; mean lateral incisor-to-canine width ratios were 85.3% and 81.4% and lateral incisor percentage offsets were 9.6% and 8.7%. There were significant (p<0.05) differences for before and after treatment for all variables except central-to-lateral incisor width ratio. Differences between specialist and general dentist were not statistically significant. CONCLUSIONS: On average, esthetic prosthetic treatment resulted in reduced central incisor width-to-height ratio, increased proportional width of the mesially positioned tooth of adjacent anterior teeth and reduced lateral incisor offset. The mean values of treatments by GPs and prosthodontists were not statistically significantly different. CLINICAL IMPLICATIONS: Knowledge of dentists' optimal restorative treatments provides insight on the esthetic outcome of extensive prosthodontic therapy.

Analysis of an administrative database of indirect restorations over 11 years.

AIM: This paper describes the database used to assess the survival of indirect restorations and presents general data on survival of these restorations. METHODS: Data, based on the complete attendance and treatment history, over the 11 years from 1991 to 2001, of a statistically representative sample of 23,165 General Dental Services' (GDS) patients in England and Wales, all of whom received at least one indirect restoration during the observation period, have been analysed. The patients on the database received a total of 36,397 courses of treatment, and there were 52,481 indirect restorations placed. The method of analysis involved the estimation of the probability that the patient will eventually return, given an interval without attending, by analysing the observed patterns of re-attendance. This estimated probability of re-attendance was then used to modify the standard Kaplan-Meier procedure to produce realistic estimates of the hazard of re-intervention. RESULTS: Overall, 75% of indirect restorations remained without re-intervention after 5 years, and 61% after 10. Crowns outperformed other types of indirect restoration. Multi-surface metal inlays, by contrast, had a median interval to re-intervention of less than 8 years. CONCLUSIONS: The times to re-intervention for different types of indirect restoration have been successfully estimated and crowns shown to outperform veneers and inlays.