Experimental study on the use of spacer foils in two-step putty and wash impression procedures using silicone impression materials.

STATEMENT OF PROBLEM: The 2-step putty and wash impression technique is commonly used in fixed prosthodontics. However, cutting sluiceways to allow the light-body material to drain is time-consuming. A solution might be the use of a spacer foil. PURPOSE: The purpose of this study was to evaluate the influence of spacer foil on the margin reproduction and dimensional accuracy of 2-step putty and wash impressions. MATERIAL AND METHODS: Two methods of creating space for the wash material in a 2-step putty and wash impression were compared: the traditional cutout technique and a spacer foil. Eleven commercially available combinations of silicone impression materials were included in the study. The impressions and the cast production were carried out under standardized conditions. All casts were measured with a 3-dimensional (3D) coordinate measuring machine. Preparation margin reproduction and the diameters and spacing of the stone cast dies were measured (α=.05). RESULTS: The 2 methods showed significant differences (P<.05) in the reproduction of the preparation margins (complete reproduction cutout, 90% to 98%; foil, 74% to 91%). The use of a foil resulted in greater dimensional accuracy of the cast dies compared to the cutout technique. Cast dies from the cutout technique were significantly smaller than the metallic original cast (cutout median, 4.55 mm to 4.61 mm; foil median, 4.61 to 4.64). Spacing between the dies revealed only a few additional significant differences between the techniques. CONCLUSIONS: When spacer foils were used, dies were obtained that better corresponded to the original tooth.

Evaluation of a virtual reality simulation system for porcelain fused to metal crown preparation at Tokyo Medical and Dental University.

The use of virtual reality simulation (VRS) is a new teaching modality in dentistry, and there is scope for further research evaluating its use under different educational programs. The purpose of this study was to evaluate how VRS with or without instructor feedback influenced students' learning and skills related to porcelain fused to metal (PFM) crown preparation. In this study, forty-three dental students in their fifth year of study at Tokyo Medical and Dental University, Tokyo, Japan, were randomly divided into three groups: the first group used VRS (DentSim) with the instructor's feedback (DSF) (n=15), the second group used VRS without the instructor's feedback (DS) (n=15), and the third group neither used features of VRS (NDS) (n=13) nor received the instructor's feedback. All the students performed PFM crown preparation under the same setup once a week for four weeks. Total scores, preparation time, and twelve evaluation items were compared among the three groups and four experiments. The total scores of students in the DSF and DS groups were significantly higher than those in the NDS group. The presence of the instructor did not result in significant difference when VRS was used for training, while it shortened the preparation time at early stages. The results of this study suggested that the use of the VRS system improved student training for PFM crown preparation.

Establishing a classification system and criteria for veneer preparations.

The concept of no- or minimal-preparation veneers is more than 25 years old, yet there is no classification system categorizing the extent of preparation for different veneer treatments. The lack of veneer preparation classifications creates misunderstanding and miscommunication with patients and within the dental profession. Such a system could be indicated in various clinical scenarios and would benefit dentists and patients, providing a guide for conservatively preparing and placing veneers. A classification system is proposed to divide preparation and veneering into reduction--referred to as space requirement, working thickness, or material room--volume of enamel remaining, and percentage of dentin exposed. Using this type of metric provides an accurate measurement system to quantify tooth structure removal, with preferably no reduction, on a case-by-case basis, dissolve uncertainty, and aid with multiple aspects of treatment planning and communication.

Fracture strength of minimally prepared all-ceramic CEREC crowns after simulating 5 years of service.

OBJECTIVES: To examine the strength and mode of fracture of traditionally and minimally prepared all-ceramic resin bonded CAD/CAM crowns after fatigue loading. METHODS: Thirty human maxillary molars were used and divided in three groups namely; traditional crown preparation group (I), minimal crown preparation group (II) and occlusal veneer preparation group (III). A leucite reinforced glass ceramic (IPS Empress CAD) was used for fabricating the crowns. The CEREC InEOS system (v3.10) was used for scanning, designing and milling. Five years of clinical service were simulated and the fracture strength of the crowns was measured. One-way ANOVA and Kruskal-Wallis test were used for data analysis (α=0.05). RESULTS: The mean fracture strength and SD in Group I was 1070N (±181) and in Group II 1110N (±222). One-way ANOVA analysis showed no statistically significant difference between the two groups (p>0.05). In Group III all restorations developed cracks during TCML and were not subjected to fracture loading. Three of the traditionally designed crowns (Group I) and 4 of the minimally designed crowns (Group II) developed surface cracks during TCML. SIGNIFICANCE: Minimal all-ceramic resin-bonded crowns can potentially form a viable restorative option as they demonstrated comparable strength to traditional all-ceramic crowns. However, this should be interpreted with caution as a number of crowns showed cracks after 5 years of simulated service. All the occlusal veneers developed cracks during simulation and further investigation is needed for this to be considered a viable option.

In vitro analysis of residual tooth structure of maxillary anterior teeth after different prosthetic finish line preparations for full-coverage single crowns.

To evaluate residual dentin thickness (RDT) after different tooth preparations, 90 sound maxillary anterior teeth were selected and divided into 3 groups according to tooth type (n = 30), namely, maxillary central incisors, maxillary lateral incisors, and maxillary canines. In each group, specimens were randomly divided and prepared for single-crown coverage with shoulder (SHO, n = 10, control), slight chamfer (CHA, n = 10), and knife-edge (KNE, n = 10) finish lines. After tooth preparation, specimens were sectioned and divided into 4 subgroups (buccal, distal, palatal, and mesial) according to measurement area. RDT values were compared by using one-way ANOVA and Tukey's post hoc test (P = 0.05). Significant differences were found between SHO and the other two groups (P < 0.05) but not between CHA and KNE (P > 0.05). SHO was significantly more aggressive than CHA and KNE, which were comparable. Interproximal areas became critical due to thin RDT, which could potentially compromise the structural and biological integrity of teeth. The choice of finish line should be guided by careful clinical evaluation.

The effects of scaling and root planing on the marginal gap and microleakage of indirect composite crowns prepared with different finish lines: an in vitro study.

The present in vitro study aimed to assess the effects of root surface mechanical instrumentation on the marginal integrity and adaptation of resin composite crowns. The following null hypotheses were tested: no differences exist between finish line and 1) marginal gap or 2) marginal microleakage before and after manual mechanical periodontal maintenance. A total of 56 intact human mandibular molars were randomly distributed into four groups and subjected to standardized tooth preparations for indirect composite crowns with different marginal finish lines (90° shoulder, beveled 90° shoulder, feather edge, chamfer). One-half of the specimens was used as a control and remained untreated, and the remaining half was subjected to root surface procedures simulating five years of semestral mechanical supportive periodontal treatment. The marginal gap and microleakage were evaluated and statistically analyzed. The specimens used as controls showed lower mean marginal gaps than those subjected to the simulated periodontal treatment, whereas the latter showed lower microleakage than the control crowns. Statistically significant differences were recorded for both the experimental variables. The root surface procedures resulted in altered surfaces of the composite crowns. The marginal gap increased after the treatment, whereas the marginal microleakage was reduced. The 90° shoulder and the chamfer preparation could be considered a viable option to fabricate composite crowns, but the beveled 90° shoulder and the feather edge should not be recommended.

Comparison of the marginal adaptation of zirconium dioxide crowns in preparations with two different finish lines.

PURPOSE: The purpose of this study was to evaluate the marginal adaptation of zirconium dioxide crowns in preparations with two different finish line configurations before and after porcelain firing cycles, after a glaze cycle, and after cementation. MATERIALS AND METHODS: Twenty human molar teeth were prepared to receive full crowns; ten were prepared with a 90° round shoulder and another ten with a 45° chamfer finish line. Zirconium dioxide copings were fabricated using CAD/CAM technology (Lava™ system). They were then veneered with a low-fusing glass-ceramic (IPS e.max® Ceram). Finally, they were glazed and cemented with a resin-composite cement (RelyX™ Unicem, Aplicap™). Measurements for marginal adaptation using stereomicroscopy (40×) were performed at four stages: copings (S1), after porcelain firing cycles (S2), after glazing (S3), and after cementation (S4). One-way ANOVA was used to assess the influence of the finish line design on the marginal adaptation in each stage. Two-way ANOVA with repeated measurements was performed to assess the influence on the marginal adaptation of the porcelain firing cycles, glaze firing cycle, and cementation. RESULTS: The measured marginal gap mean values for the shoulder group (µm) were: 50.13 (S1), 54.32 (S2), 55.12 (S3), and 59.83 (S4). The values for the chamfer group were: 63.56 (S1), 71.85 (S2), 74.12 (S3), and 76.97 (S4). When comparing marginal gaps between specimens with two different finish lines, differences were noticed at the four studied stages (p = 0.0165, p = 0.0027, p = 0.0009, and p = 0.0009, respectively). No differences were manifested in the marginal gap measurements of the shoulder group at the different stages of fabrication (p = 0.4335); however, in the chamfer group, differences were noticed between S1 and S3 (p = 0.0042). CONCLUSIONS: Marginal adaptation was influenced by the finish line design. The firing cycles significantly affected the chamfer group; nevertheless, the marginal gap was within the range of clinical acceptability.

Influence of crown ferrule heights and dowel material selection on the mechanical behavior of root-filled teeth: a finite element analysis.

PURPOSE: This study used the 3D finite element (FE) method to evaluate the mechanical behavior of a maxillary central incisor with three types of dowels with variable heights of the remaining crown structure, namely 0, 1, and 2 mm. MATERIALS AND METHODS: Based on computed microtomography, nine models of a maxillary central incisor restored with complete ceramic crowns were obtained, with three ferrule heights (0, 1, and 2 mm) and three types of dowels (glass fiber = GFD; nickel-chromium = NiCr; gold alloy = Au), as follows: GFD0--restored with GFD with absence (0 mm) of ferrule; GFD1--similar, with 1 mm ferrule; GFD2--glass fiber with 2 mm ferrule; NiCr0--restored with NiCr alloy dowel with absence (0 mm) of ferrule; NiCr1--similar, with 1 mm ferrule; NiCr2--similar, with 2 mm ferrule; Au0--restored with Au alloy dowel with absence (0 mm) of ferrule; Au1--similar, with 1 mm ferrule; Au2--similar, with 2 mm ferrule. A 180 N distributed load was applied to the lingual aspect of the tooth, at 45° to the tooth long axis. The surface of the periodontal ligament was fixed in the three axes (x = y = z = 0). The maximum principal stress (σ(max)), minimum principal stress (σ(min)), equivalent von Mises (σ(vM)) stress, and shear stress (σ(shear)) were calculated for the remaining crown dentin, root dentin, and dowels using the FE software. RESULTS: The σ(max) (MPa) in the crown dentin were: GFD0 = 117; NiCr0 = 30; Au0 = 64; GFD1 = 113; NiCr1 = 102; Au1 = 84; GFD2 = 102; NiCr2 = 260; Au2 = 266. The σ(max) (MPa) in the root dentin were: GFD0 = 159; NiCr0 = 151; Au0 = 158; GFD1 = 92; NiCr1 = 60; Au1 = 67; GFD2 = 97; NiCr2 = 87; Au2 = 109. CONCLUSION: The maximum stress was found for the NiCr dowel, followed by the Au dowel and GFD; teeth without ferrule are more susceptible to the occurrence of fractures in the apical root third.

The accuracy of optical scanning: influence of convergence and die preparation.

The purpose of this study was to determine the reliability of the data acquisition and modeling process of laser and white light scanners by evaluating the reproducibility of digitized simulated crowns with different convergences. A secondary purpose was to analyze the influence of die preparation by testing this hypothesis with a set of dies without ditching compared with a set with well-defined margins. Ditching or trimming the die defines the position of the margin and acts as a guide to gingival contour when the restoration is being waxed. Two light scanners (a white light optical scanner [Steinbichler Gmbh, Neubeuern, Germany] and red laser light scanner [TurboDent System, Taichung, Taiwan]) were evaluated. Two sets of simulated crowns were fabricated as cone frustrum models with a total occlusal convergence (TOC) of 0°, 5°, 10°, 15°, 20°, and 25° and a 9-mm base and 3-mm height using a precision milling machine and computer-aided design/computer-aided manufacturing (CAD/CAM) technique. One set of the dies was ditched immediately below the finish line to enhance marginal definition. Each die was optically digitized five times directly with the two different measuring systems. The area of each triangle in the scan that is occlusal to the margin line was calculated and summed to produce the final surface area measurement provided. The digitizing error was compared with the computed surface area of the original master die sets and compared with a paired t-test (df=4; 95% CI). There was no difference in accuracy of the untrimmed dies between the two systems evaluated. We also did not find any difference in the 0° (p=0.12) and 5° degree (p=0.21) groups among the ditched dies. However, when the TOC exceeded 5°, there was a significant difference between the two groups, with the laser groups having a smaller error percentage. Three-dimensional light scanning was not affected by the convergence angle except in the 0°-5° range. Trimming the dies greatly affected the accuracy of scanning.

Tensile bond strength of ceramic crowns to dentin using resin cements.

PURPOSE: This study measured the bond strength of the self-adhesive resin cements and a bonded resin cement for crowns bonded to extracted teeth with preparations having a total taper greater than 30 degrees. A crown pull-off test was used with direction of pull along the path of insertion. The CAD/CAM system Cerec was used to create crowns with the pull-off loop as an integral part of the crown structure. MATERIALS AND METHODS: One hundred extracted human molars were prepared for all-ceramic crowns with a 1.5-mm shoulder, greater than 30-degree axial wall convergence, a flat occlusal surface and 3 to 5 mm occlusal/ gingival height. All-ceramic crowns were cemented with five different self-adhesive cements (Rely X Unicem, Maxcem Elite, BisCem, SmartCem 2, and G-Cem) and one bonded resin cement (Multilink). Forfour cements (excluding GCem and Multilink) there were 2 groups, one with HF etching and one without ceramic surface treatment. The crowns were then subject to tensile stress until either the crown fractured or the crown was lifted off from the tooth. RESULTS: For several cements, the bond strength exceeded the tensile strength of the all-ceramic crown; thus, the crown fractured, leaving the cemented part of the crown on the tooth. The effect of ceramic surface etching was not statistically significant at p = 0.05; however, for each cement, the treated crowns showed a lower coefficient of variance (COV). For this study, the COV ranged from 24.9 % to 97.9 %. Loads ranged from 41.3 to 190.3 N. CONCLUSION: Some of the new self-etching resin cements can create bonds to non-retentive crown preparations that are stronger than the strength of a ceramic crown; however, these high bond strengths may not be able to be achieved consistently.

Rethinking ferrule--a new approach to an old dilemma.

The 'ferrule effect' is a long standing, accepted concept in dentistry that is a foundation principle for the restoration of teeth that have suffered advanced structure loss. A review of the literature based on a search in PubMed was performed looking at the various components of the ferrule effect, with particular attention to some of the less explored dimensions that influence the effectiveness of the ferrule when restoring severely broken down teeth. These include the width of the ferrule, the effect of a partial ferrule, the influence of both, the type of the restored tooth and the lateral loads present as well as the well established 2 mm ferrule height rule. The literature was collaborated and a classification based on risk assessment was derived from the available evidence. The system categorises teeth according to the effectiveness of ferrule effect that can be achieved based on the remaining amount of sound tooth structure. Furthermore, risk assessment for failure can be performed so that the practitioner and patient can better understand the prognosis of restoring a particular tooth. Clinical recommendations were extrapolated and presented as guidelines so as to improve the predictability and outcome of treatment when restoring structurally compromised teeth. The evidence relating to restoring the endodontic treated tooth with extensive destruction is deficient. This article aims to rethink ferrule by looking at other aspects of this accepted concept, and proposes a paradigm shift in the way it is thought of and utilised.

Effect of cervical relining of acrylic resin copings on the accuracy of stone dies obtained using a polyether impression material.

The purpose of this study was to evaluate the accuracy of the respective dies after polyether elastomeric procedure in the presence or absence of cervical contact of the acrylic resin shell with the cervical region, establishing a comparison to dies obtained with stock trays. This study consisted of three groups with 10 specimens each: 1) acrylic copings without cervical contact, (cn); 2) acrylic copings with cervical contact (cc); 3) perforated stock tray, (st). The accuracy of the resulting dies was verified with the aid of a master crown, precisely fit to the master steel die. ANOVA test found statistically significant differences among groups (p<0.001). Tukey's test found that the smallest discrepancy occurred in group cn, followed by cc, while the st group presented the highest difference (cc x cn: p=0.007; st x cn: p<0.001; st x cc: p<0.001).

Photoconductive method for measuring light transmission to the root of metal-ceramic and all-ceramic restorations.

OBJECTIVES: In this study, the authors attempted to develop a photoconductive method for measuring light transmission through a crown restoration to the root dentin; metal-ceramic crowns with four coping designs (metal collar, and metal framework ending 0, 1, and 2mm coronal to the axiogingival line angle) and two all-ceramic crowns (Empress II and In-Ceram Alumina) were compared. METHODS: According to pre-registered templates, 36 crowns were fabricated for an extracted central incisor. A cadmium sulfide (CdS) photoconductive cell was secured onto the root of a tooth, which was fixed in a light box. The validity and reliability of the experimental design were verified, and the impedance of the cell was recorded when the crowns were placed on the prepared tooth with or without try-in pastes under a constant luminance. RESULTS: A significant correlation (r= -0.99, p<0.001) was found between the light intensity and impedance of the CdS cell, and a 1.15% coefficient of variation between repeated measurements was observed. In this study, Empress II crowns had the smallest impedance, indicating that they provided the best light transmission. Conventional metal-ceramic crowns had the least light transmission, which was significantly improved by reducing the metal collar (p<0.05). The framework of metal-ceramic crowns which ended 2mm coronal to the axiogingival line angle showed as much light transmission as the In-Ceram crowns. The impedance increased when try-in pastes were employed in all test groups. SIGNIFICANCE: The photoconductive method was proven to be a reliable technique for measuring the light transmitted through restorations into the adjacent tissue.

Effect of cervical relining of acrylic resin copings on the accuracy of stone dies obtained using a polyether impression material

The purpose of this study was to evaluate the accuracy of the respective dies after polyether elastomeric procedure in the presence or absence of cervical contact of the acrylic resin shell with the cervical region, establishing a comparison to dies obtained with stock trays. This study consisted of three groups with 10 specimens each: 1) acrylic copings without cervical contact, (cn); 2) acrylic copings with cervical contact (cc); 3) perforated stock tray, (st). The accuracy of the resulting dies was verified with the aid of a master crown, precisely fit to the master steel die. ANOVA test found statistically significant differences among groups (p<0.001). Tukey's test found that the smallest discrepancy occurred in group cn, followed by cc, while the st group presented the highest difference (cc x cn: p=0.007; st x cn: p<0.001; st x cc: p<0.001).

Precision of fit of two margin designs for metal-ceramic crowns.

STATEMENT OF PROBLEM: Although metal-ceramic restorations are widely used, there is a lack of information about how the fit is affected by margin designs. PURPOSE: This study measured and compared the precision of fit of metal-ceramic crowns with two margin designs. MATERIAL AND METHODS: Thirty-two extracted human premolar teeth were prepared for complete-coverage restorations with an internally rounded shoulder preparation. Impressions were made from all teeth, and master dies were poured with improved stone type V. MC crowns were fabricated with a porcelain-butt margin on the buccal aspect (n = 32) and a feather-edge metal margin on the lingual aspect (n = 32), which served as a control group. Precision of fit was measured three times at the mid-buccal and mid-lingual margins of each crown with a profilometer. The data were statistically analyzed with the paired t-test (alpha < .05). RESULTS: Mean marginal gap size of porcelain-butt margins was 27.93 microm (+/-15.84) and of feather-edge metal margins 42.43 microm (+/-24.12). The marginal gap size of feather-edge metal margins was statistically significantly greater than that of porcelain-butt margins (p = 0.0045). CONCLUSION: The marginal fit of porcelain-butt margins was significantly better than that of feather-edge metal margins. CLINICAL IMPLICATIONS: Porcelain-butt margins in this study had a better marginal fit than feather-edge metal margins, and thus have given clinicians evidence to prefer the use of porcelain-butt margins.

Crowns and other extra-coronal restorations: preparations for full veneer crowns.

Preparations for full veneer crowns is the eighth in the series on crowns and other extra-coronal restorations. Whilst handpiece skills are important, many other factors combine to ensure provision of a satisfactory full veneer crown (also termed 'full coverage crown'). Our aim in writing this article is to consider the principles which influence crown preparation, seasoned with clinical advice our undergraduate and postgraduate students have found useful.

Tooth preparations for complete crowns: an art form based on scientific principles.

STATEMENT OF THE PROBLEM: No recent literature has reviewed the current scientific knowledge on complete coverage tooth preparations. PURPOSE: This article traces the historic evolution of complete coverage tooth preparations and identifies guidelines for scientific tooth preparations. MATERIAL AND METHODS: Literature covering 250 years of clinical practice was reviewed with emphasis on scientific data acquired during the last 50 years. Both a MEDLINE search and an extensive manual search were used to locate relevant articles written in English in the last 50 years. RESULTS: Teeth should be prepared so that they exhibit the following characteristics: 10 to 20 degrees of total occlusal convergence, a minimal occlusocervical dimension of 4 mm for molars and 3 mm for other teeth, and an occlusocervical-to-faciolingual dimension ratio of 0.4 or greater. Facioproximal and linguoproximal line angles should be preserved whenever possible. When the above features are missing, the teeth should be modified with auxiliary resistance features such as axial grooves or boxes, preferably on proximal surfaces. Finish line selection should be based on the type of crown/retainer, esthetic requirements, ease of formation, and personal experience. Expectations of enhanced marginal fit with certain finish lines could not be validated by recent research. Esthetic requirements and tooth conditions determine finish line locations relative to the gingiva, with a supragingival location being more acceptable. Line angles should be rounded, and a reasonable degree of surface smoothness is desired. CONCLUSIONS: Nine scientific principles have been developed that ensure mechanical, biologic, and esthetic success for tooth preparation of complete coverage restorations.

Shades of a color. Illusion or reality?

Attaining the highest clinical level in esthetic and cosmetic dentistry necessitates the development of artistic skills; of balancing illusion with reality. The shade of a tooth is a combination of color and light and varies in different light conditions. Understanding the differences in color shades is the basis to creating illusions. Understanding light and color, and the reality of illusions, allows the clinician to design and sculpt a smile, to modify a flawed display artistically so that patients may perceive it as natural and more attractive, and to design laminates and veneers, class III, class IV, and cervical cavities.