Structural and torque changes in implant components of different diameters subjected to mechanical fatigue.

OBJECTIVES: To evaluate torque maintenance and structural damage in implant components of different diameters subjected to a fatigue challenge. METHODS: Thirty 10-mm-long, morse taper connection, titanium dental implants and their corresponding one-piece abutments were divided into three groups (n = 10) according to implant diameter: 4.3 mm (I4.3), 3.5 mm (I3.5), and 2.9 mm (I2.9). The implants were placed into a load-bearing fixture simulating bone tissue (modified G10), and the abutments were screwed into the implants to a final torque of 20 Ncm for the I4.3 and I3.5 and 15 Ncm for I2.9. The torque was secured by a digital torque meter. Cone-beam computed tomography (CBCT) scans were acquired and post-processed (e-Vol DX software) for all implant/abutment sets before and after subjecting them to fatigue in 37 °C distilled water (2 million cycles, constant load and frequency). The removal torque was measured using the same digital torque meter to calculate the difference in torque before and after fatigue. RESULTS: I2.9 showed substantial structural deformation compared with the other implant diameters (I3.5 and I4.3). However, the experimental groups did not show statistical differences for abutment loosening. SIGNIFICANCE: Implants smaller than 3.5 mm in diameter have a higher probability of structural deformation than standard-diameter implants. The association between tomographic scans and e-Vol DX software showed satisfactory consistency with the direct assessment using the digital torque meter, offering an additional tool to evaluate implant component loosening and structural deformations.

Optimization of Lithium Disilicate Glass-Ceramic Crowns: Finish Line, Scanning, and Processing Methods.

PURPOSE: To investigate the optimal combination of factors (finish line, scanning, and ceramic processing) to achieve the best values of both adaptation and fracture load for lithium disilicate crowns (LD). MATERIALS AND METHODS: Two abutment preparations, chamfer (C) and rounded shoulder (S), were produced with a dentin analog material and scanned with either extraoral (E) or intraoral (I) scanners. Images were processed using CAD software to design a premolar. Blocks of LD were milled using a CAD/CAM system (CAD). For the press technique (PRE), crowns were first 3D printed using a polymeric material, then heat-pressing protocol was performed. Design of experiments was used to plan four experimental groups (n = 10): CAD-CI, CAD-SE, PRE-CE, and PRE-SI. Two dependent variables were analyzed: adaptation, measured using the replica technique; and fracture load of the cemented crowns. Fractographic analysis was performed. Data were analyzed using ANOVA and regression statistical analyses. RESULTS: There was no significant effect of the scanning method and finish line on the gap thickness in the different regions. For the processing method, CAD resulted in larger gap thickness in the occlusal, axial angle, and marginal areas and a smaller gap in the axial area (P < .001). The investigated factors had no effect on the fracture load. Yet, PRE-CE was considered the optimum design because it achieved 100% of the desired fracture load (>1000 N) and 40% adaptation (< 200 µm). CONCLUSIONS: The optimum combination of factors for all-ceramic crowns is chamfer abutment preparation, extraoral scanning, and the press technique (combined with 3D printing). Int J Prosthodont 2023;36:e103-e118.

Effects of ZnO/TiO2 nanoparticle and TiO2 nanotube additions to dense polycrystalline hydroxyapatite bioceramic from bovine bones.

OBJECTIVES: A bovine dense hydroxyapatite ceramic (HA) was produced as new biomaterial, however, the production of a material with consistently high flexural strength remains challenging. The objective of this study was to evaluate the effects of ZnO nanoparticles, TiO2 nanoparticles, and TiO2 nanotubes (1%, 2%, and 5% by weight) on the microstructure and flexural strength of a bovine dense hydroxyapatite ceramic (HA). METHODS: Discs (Ø=12.5mm; thickness=1.3mm) were prepared and subjected to X-ray diffraction (XRD), and observation with a field emission scanning electron microscope (FE-SEM), biaxial flexural strength (BFS) testing, and Vickers hardness (VH) testing. The BFS and VH data were subjected to ANOVA and Tukey post-hoc tests (α=0.05) and Weibull analysis. RESULTS: The XRD showed that the addition of nanomaterials caused the formation of a secondary phase when 5% of the ZnO nanoparticles was used, or when all percentages of the TiO2 nanoparticles/nanotubes were used, and the HA crystallographic planes were maintained. Differences were not observed between the higher BFS values obtained with pure HA and those obtained with the 5% addition of TiO2 nanoparticles. However, the results were different compared with the other groups (α=0.05). The results obtained by Weibull analysis revealed that the 1%, 2%, and 5% addition of TiO2 nanotubes, and the 1% and 2% addition of TiO2 nanoparticles decreased the HA characteristic strength (σ0), while the Weibull modulus (m) increased when 5% of TiO2 nanoparticles, 1% and 2% of ZnO nanoparticles, and 2% of TiO2 nanoparticles were added, but with no statistical difference from the pure HA. The 5% addition of ZnO2 nanoparticles decreased the σ0 without changing m. Moreover, the 5% addition of TiO2 nanoparticles resulted in an m closest to that of pure HA. Regarding the VH results, the blend of HA with 1% and 2% addition of TiO2 nanoparticles exhibited the higher values, which were similar between the different addition ratios (p=0.102). Moreover, the addition of 5% TiO2 nanoparticles resulted in higher value compared with pure HA. SIGNIFICANCE: This study demonstrated that the HA blend with 5% of TiO2 nanoparticles has the greatest potential as a bovine HA dense bioceramic reinforcement.

Fatigue Behavior of Crystalline-Reinforced Glass-Ceramics.

PURPOSE: To evaluate the fatigue behavior of two crystalline-reinforced ceramics: leucite-reinforced (VL) and lithium disilicate-based (VD) glass-ceramics. MATERIALS AND METHODS: Bar-shaped specimens (16 × 4 × 1.2 mm) were produced for each ceramic using prefabricated CAD/CAM blocks. For each group, 30 specimens were subjected to a three-point flexural strength test in a universal testing machine. For VL and VD, 36 and 41 specimens were subjected to a cyclic fatigue test, respectively. The cyclic fatigue test was performed with a pneumatic mechanical cycling machine (1 Hz; 37°C distilled water). Specimens were tested at two stress levels for each preset lifetime (103 and 104 cycles for VL; 104 and 105 cycles for VD) following the boundary technique. Fractography was performed with a scanning electron microscope. Data were analyzed with Weibull analysis. RESULTS: There were significant differences among groups for characteristic strength (σ0 ) and Weibull modulus (m), as the confidence intervals did not overlap. The VD group presented the highest values of σ0 , but the lowest Weibull modulus. Both groups showed a reduction of approximately 60% of the initial flexural strength (σf ) after cycling for 104 cycles. For VD tested in fatigue, there was no degradation of σf when the number of cycles was increased from 104 to 105 . The VL group showed an 18% decrease in σf when the number of cycles increased from 103 to 104 . Flexural strength values estimated for a 5% probability of failure were 36 MPa for VL and 55 MPa for VD, after 104 cycles. CONCLUSION: Both glass-ceramics showed similar strength degradation (60%) after a lifetime of 104 cycles, despite their distinct mechanical properties. Mechanical cycling in humid conditions proved to be an important factor for the degradation of the mechanical properties of crystalline-reinforced glass-ceramics.

Dimensional changes from the sintering process and fit of Y-TZP copings: Micro-CT analysis.

OBJECTIVE: To evaluate the dimensional changes from the sintering process of Y-TZP and relate them to the fit of zirconia copings. METHODS: The sintering shrinkage rate (SSR) was obtained from the measurement of geometric specimens (4×4×2mm). Thirty-six zirconia copings made using CAD/CAM were equally divided into three groups (n=12): ZMAX - IPS e.max ZirCAD (Ivoclar Vivadent, Liechtenstein); ZYZ - InCeram YZ (Vita Zahnfabrik, Germany); and ZK - Zirklein (Zirklein, Brazil). The copings were scanned in micro-CT before and after sintering so that SSR was obtained. The SSR of geometrical specimens and copings was compared to each other and those the manufacturers reported (ANOVA-2 and Tukey, p≤.05). The copings were settled on an abutment and taken to the micro-CT to evaluate their marginal and internal fit. The data enabled the statistical comparison (ANOVA-2 and Tukey, p≤.05) between groups and measurement sites and between the fit obtained with that stipulated by the CAD/CAM software (80µm) (Dunnett test, p≤.05). RESULTS: All groups showed statistical differences between the SSR the manufacturer reported and those obtained experimentally and between the SSR of the geometric specimens and copings. In general, the SSR of the copings showed no uniformity. There was no statistical difference among the groups for marginal fit, with differences only for internal fit and between the different regions measured. The fit obtained experimentally differed from the internal space determined in the CAD/CAM software. SIGNIFICANCE: The lack of uniformity of sintering shrinkage might lead to a non-uniform internal fit of Y-TZP copings.

Effect of cement space on stress distribution in Y-TZP based crowns.

OBJECTIVE: To evaluate the stress distribution in bi-layered Y-TZP based crowns, according to the occlusal internal spacing between coping and abutment. METHODS: Twelve premolar shaped Y-TZP copings were made by a CAD/CAM system and seated on an abutment to evaluate the internal fit at the occlusal third using micro-CT images. Considering the fitting range obtained experimentally, two 3D finite element models, consisting on bone tissue, a titanium implant, a zirconia abutment, cement layer and a bi-layered Y-TZP ceramic crown were constructed based on the micro-CT images, one corresponding to the thinnest cement space and other representing the specimen with the thickest cement space obtained experimentally. A 250N axial load was applied at the center of the occlusal surface of the crown (≅0,8mm2 area) and the first principal stress distribution was plotted and analyzed. RESULTS: The greatest maximum principal stress occurred within the veneer ceramic right below the site of loading. The thickest cement model showed higher stress concentration at the center of occlusal surface of veneer and the center of occlusal internal surface of coping. SIGNIFICANCE: Knowledge of stress distribution in ceramic crowns with different cement thicknesses will help clinicians to properly adjust crown fit, in seeking to avoid porcelain fractures.

An Indirect Method to Measure Abutment Screw Preload: A Pilot Study Based on Micro-CT Scanning

This study aimed to measure the preload in different implant platform geometries based on micro-CT images. External hexagon (EH) implants and Morse Tapered (MT) implants (n=5) were used for the preload measurement. The abutment screws were scanned in micro-CT to obtain their virtual models, which were used to record their initial length. The abutments were screwed on the implant with a 20 Ncm torque and the set composed by implant, abutment screw and abutment were taken to the micro-CT scanner to obtain virtual slices of the specimens. These slices allowed the measurement of screw lengths after torque application and based on the screw elongation. Preload values were calculated using the Hooke's Law. The preloads of both groups were compared by independent t-test. Removal torque of each specimen was recorded. To evaluate the accuracy of the micro-CT technique, three rods with known lengths were scanned and the length of their virtual model was measured and compared with the original length. One rod was scanned four times to evaluate the measuring method variation. There was no difference between groups for preload (EH = 461.6 N and MT = 477.4 N), but the EH group showed higher removal torque values (13.8±4.7 against 8.2±3.6 Ncm for MT group). The micro-CT technique showed a variability of 0.053% and repeatability showed an error of 0.23 to 0.28%. Within the limitations of this study, there was no difference between external hexagon and Morse taper for preload. The method using micro-CT may be considered for preload calculation.

Resumo Este estudo teve como objetivo medir a pré-carga em diferentes conexões implante/pilar baseado em imagens de micro-CT. Implantes de hexágono externo (EH) e Cone Morse (MT) (n = 5) foram utilizados para a medição de pré-carga. Os parafusos de pilares foram digitalizados em um micro-CT de alta resolução para obter seus modelos virtuais, que foram utilizados para registrar o comprimento inicial. Os pilares foram parafusados sobre o implante com um torque de 20 Ncm e, o conjunto composto por implante, parafuso do pilar e pilar foi levado para o micro-CT para obter cortes virtuais dos espécimes. Esses cortes permitiram a medida do comprimento dos parafusos após a aplicação do torque. Assim, com base no alongamento dos parafusos, os valores de pré-carga foram calculados usando a Lei de Hooke. A pré-carga de ambos os grupos foram comparados pelo Test-t independente. O torque de remoção de cada espécime foi registrado. Para avaliar a precisão da técnica de micro-CT, três bastões foram escaneados em micro-CT e o comprimento do seu modelo virtual foi comparado com o comprimento original dos bastões. Um bastão foi digitalizado e mensurado quatro vezes para avaliar a variação do método de medição e a sua repetitividade. Não houve diferença entre os grupos para a pré-carga (EH = 461,6 N e MT = 477,4 N), no entanto o grupo EH apresentou maiores valores de torque de afrouxamento do parafuso (13,8 ± 4,7 contra 8,2 ± 3,6 Ncm para o grupo MT). A técnica de micro-CT mostrou uma variabilidade de 0,053% e a repetitividade apresentou um erro de 0,23 a 0,28%. Dentro das limitações deste estudo, não houve diferença entre Hexágono Externo e Cone Morse para pré-carga. O método baseado em imagens de micro-CT pode ser considerado para mensuração da pré-carga.

An Indirect Method to Measure Abutment Screw Preload: A Pilot Study Based on Micro-CT Scanning.

This study aimed to measure the preload in different implant platform geometries based on micro-CT images. External hexagon (EH) implants and Morse Tapered (MT) implants (n=5) were used for the preload measurement. The abutment screws were scanned in micro-CT to obtain their virtual models, which were used to record their initial length. The abutments were screwed on the implant with a 20 Ncm torque and the set composed by implant, abutment screw and abutment were taken to the micro-CT scanner to obtain virtual slices of the specimens. These slices allowed the measurement of screw lengths after torque application and based on the screw elongation. Preload values were calculated using the Hooke's Law. The preloads of both groups were compared by independent t-test. Removal torque of each specimen was recorded. To evaluate the accuracy of the micro-CT technique, three rods with known lengths were scanned and the length of their virtual model was measured and compared with the original length. One rod was scanned four times to evaluate the measuring method variation. There was no difference between groups for preload (EH = 461.6 N and MT = 477.4 N), but the EH group showed higher removal torque values (13.8 ± 4.7 against 8.2 ± 3.6 N cm for MT group). The micro-CT technique showed a variability of 0.053% and repeatability showed an error of 0.23 to 0.28%. Within the limitations of this study, there was no difference between external hexagon and Morse taper for preload. The method using micro-CT may be considered for preload calculation.

Treatment outcomes with the use of maxillomandibular fixation screws in the management of mandible fractures.

PURPOSE: The purpose of this prospective randomized study was to assess whether uncomplicated mandible fractures could be treated successfully in an open or closed fashion using maxillomandibular fixation (MMF) screws. MATERIALS AND METHODS: This was a prospective institutional review board-approved study involving 20 adult patients who presented to the university emergency department or oral and maxillofacial surgical clinic with uncomplicated mandible fractures. Patients who met the exclusion criteria consented to enter the study in the open reduction internal fixation (ORIF) or the closed (MMF) study group. Six to 8 MMF screws were used to obtain intermaxillary fixation (IMF) in the 2 groups. Screw failure was documented. All screws were removed at 5 to 6 weeks postoperatively. Insertional torque (IT) was measured at time of screw placement to assess primary stability. Clinical and photographic documentation was performed to assess fracture healing, occlusion, and gingival health. Ten-centimeter visual analog scales were used to assess patient-centered outcomes. Cone-beam computed tomography was performed to assess the long-term effects on the periodontium and roots. A cost comparison was performed to determine whether the use of screws was cost effective compared with arch bars. RESULTS: Fifteen men and 5 women (mean age, 25.2 yr) entered the study. All patients displayed adequate fracture healing based on clinical examination. All patients had acceptable occlusion at 5 to 6 weeks postoperatively. Total screw failure was 27 of 106 screws (25.5%). Forty percent of screws placed in the MMF group failed compared with only 6% in the ORIF group. Gingival health scores were favorable. Factors that had a significant effect on screw failure included a lower IT (P = .002), use in closed (MMF) treatment (P < .001), and use in the posterior jaw (P = .012). Minimal pain was associated with the MMF screws and pre-existing occlusion was re-established based on patients' subjective responses. The MMF group reported a statistically significant lower quality of life (P < .001) compared with the ORIF group. There was only 1 screw site that had a facial cortical bone defect noted at 6-month follow-up CBCT examination. There were no discernible long-term root defects. Cost analysis showed that the use of MMF screws saved around $600 per patient in operating room usage cost alone compared with the estimated use of arch bars. CONCLUSIONS: Uncomplicated mandible fractures were successfully treated using MMF screws in open and closed treatments. However, the utility in closed treatment was decreased because of significant screw failure and patient noncompliance. The screws were well tolerated by the patients. There was minimal long-term damage to the periodontium and dental roots. The cost of screws was more than offset by time savings.