Priorities for future innovation, research, and advocacy in dental restorative materials.

Innovations in materials science, both within and outside of dentistry, open opportunities for the development of exciting direct restorative materials. From rich dialog among experts from dental and non-dental academic institutions and industry, as well as those from policy, research funding, and professional organizations, we learned that capitalizing on these opportunities is multifactorial and far from straightforward. Beginning from the point when a restoration is needed, what materials, delivery systems, and skills are needed to best serve the most people throughout the world's widely varied economic and infrastructure systems? New research is a critical element in progress. Effective advocacy can influence funding and drives change in practice and policy. Here we articulate both research and advocacy priorities, with the intention of focusing the energy and expertise of our best scientists on making a difference, bringing new innovations to improve oral health.

What constitutes an ideal dental restorative material?

Intense environmental concerns recently have prompted dentistry to evaluate the performance and environmental impact of existing restoration materials. Doing so entices us to explore the 'what if?' innovation in materials science to create more ideal restorative materials. Articulating a specification for our design and evaluation methods is proving to be more complicated than originally anticipated. Challenges exist not only in specifying how the material should be manipulated and perform clinically but also in understanding and incorporating implications of the skill of the operator placing the restoration, economic considerations, expectations patients have for their investment, cost-effectiveness, influences of the health care system on how and for whom restorations are to be placed, and global challenges that limit the types of materials available in different areas of the world. The quandary is to find ways to actively engage multiple stakeholders to agree on priorities and future actions to focus future directions on the creation of more ideal restorative materials that can be available throughout the world.

Veneer vs. core failure in adhesively bonded all-ceramic crown layers.

Joining a brittle veneer to a strong ceramic core with an adhesive offers potential benefits over current fabrication methods for all-ceramic crowns. We tested the hypothesis that such joining can withstand subsurface radial cracking in the veneer, from enhanced flexure in occlusal loading, as well as in the core. Critical conditions to initiate fractures were investigated in model crown-like layer structures consisting of glass veneers epoxy-joined onto alumina or zirconia cores, all bonded to a dentin-like polymer base. The results showed a competition between critical loads for radial crack initiation in the veneers and cores. Core radial cracking was relatively independent of adhesive thickness. Zirconia cores were much less susceptible to fracture than alumina, attributable to a relatively high strength and low modulus. Veneer cracking did depend on adhesive thickness. However, no significant differences in critical loads for veneer cracking were observed for specimens containing alumina or zirconia cores.

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

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

Enamel subsurface damage due to tooth preparation with diamonds.

In clinical tooth preparation with diamond burs, sharp diamond particles indent and scratch the enamel, causing material removal. Such operations may produce subsurface damage in enamel. However, little information is available on the mechanisms and the extent of subsurface damage in enamel produced during clinical tooth preparation. The aim of this study, therefore, was to investigate the mechanisms of subsurface damage produced in enamel during tooth preparation by means of diamond burs, and to examine the dependence of such damage on enamel rod orientation, diamond particle size, and removal rate. Subsurface damage was evaluated by a bonded-interface technique. Tooth preparation was carried out on two enamel rod orientations, with four clinical diamond burs (coarse, medium, fine, and superfine) used in a dental handpiece. The results of this study showed that subsurface damage in enamel took the form of median-type cracks and distributed microcracks, extending preferentially along the boundaries between the enamel rods. Microcracks within individual enamel rods were also observed. The median-type cracks were significantly longer in the direction parallel to the enamel rods than perpendicular to the rods. Preparation with the coarse diamond bur produced cracks as deep as 84 +/- 30 microns in enamel. Finishing with fine diamond burs was effective in crack removal. The crack lengths in enamel were not significantly different when the removal rate was varied. Based on these results, it is concluded that subsurface damage in enamel induced by tooth preparation takes the form of median-type cracks as well as inter- and intra-rod microcracks, and that the lengths of these cracks are sensitive to diamond particle size and enamel rod orientation, but insensitive to removal rate.

Mechanical characterization of dental ceramics by hertzian contacts.

Hertzian indentation testing is proposed as a protocol for evaluating the role of microstructure in the mechanical response of dental ceramics. A major advantage of Hertzian indentation over more traditional fracture-testing methodologies is that it emulates the loading conditions experienced by dental restorations: Clinical variables (masticatory force and cuspal curvature) identify closely with Hertzian variables (contact load and sphere radius). In this paper, Hertzian responses on four generic dental ceramics systems-micaceous glass-ceramics, glass-infiltrated alumina, feldspathic porcelain, and transformable zirconiaare presented as case studies. Ceramographic sectioning by means of a "bonded-interface" technique provides new information on the contact damage modes. Two distinct modes are observed: "brittle" mode, classic macroscopic fracture outside the contact (ring, or cone cracks), driven by tensile stresses; and "quasi-plastic" mode, a relatively new kind of deformation below the contact (diffuse microdamage), driven by shear stresses. A progressive transition from the first to the second mode with increasing microstructural heterogeneity is observed. The degree of quasi-plasticity is readily apparent as deviations from ideal linear elastic responses on indentation stress-strain curves. Plots of threshold loads for the initiation of both fracture and deformation modes as a function of indenter radius constitute "damage maps" for the evaluation of prospective restoration damage under typical masticatory conditions. The degree of damage in both modes evolves progressively with load above the thresholds. Strength tests on indented specimens quantify sustainable stress levels on restoration materials after damage. The most brittle responses are observed in the fine glass-ceramics and porcelain; conversely, the most quasi-plastic responses are observed in the coarse glass-ceramics and zirconia; the medium glass-ceramics and alumina exhibit intermediate responses. Implications of the results in relation to future materials characterization, selection, and design are considered in the clinical context.

Indentation damage and mechanical properties of human enamel and dentin.

Understanding the mechanical properties of human teeth is important to clinical tooth preparation and to the development of "tooth-like" restorative materials. Previous studies have focused on the macroscopic fracture behavior of enamel and dentin. In the present study, we performed indentation studies to understand the microfracture and deformation and the microcrack-microstructure interactions of teeth. It was hypothesized that crack propagation would be influenced by enamel rods and the dentino-enamel junction (DEJ), and the mechanical properties would be influenced by enamel rod orientation and tooth-to-tooth variation. Twenty-eight human third molars were used for the measurement of hardness, fracture toughness, elastic modulus, and energy absorbed during indentation. We examined the effect of enamel rod orientation by propagating cracks in the occlusal surface, and in the axial section in directions parallel and perpendicular to the occlusal surface. The results showed that the cracks in the enamel axial section were significantly longer in the direction perpendicular to the occlusal surface than parallel. The cracks propagating toward the DEJ were always arrested and unable to penetrate dentin. The fracture toughness of enamel was not single-valued but varied by a factor of three as a function of enamel rod orientation. The elastic modulus of enamel showed a significant difference between the occlusal surface and the axial section. It is concluded that the cracks strongly interact with the DEJ and the enamel rods, and that the mechanical properties of teeth are functions of microstructural orientations; hence, single values of properties (e.g., a single toughness value or a single modulus value) should not be used without information on microstructural orientation.

Materials design of ceramic-based layer structures for crowns.

Radial cracking has been identified as the primary mode of failure in all-ceramic crowns. This study investigates the hypothesis that critical loads for radial cracking in crown-like layers vary explicitly as the square of ceramic layer thickness. Experimental data from tests with spherical indenters on model flat laminates of selected dental ceramics bonded to clear polycarbonate bases (simulating crown/dentin structures) are presented. Damage initiation events are video-recorded in situ during applied loading, and critical loads are measured. The results demonstrate an increase in the resistance to radial cracking for zirconia relative to alumina and for alumina relative to porcelain. The study provides simple a priori predictions of failure in prospective ceramic/substrate bilayers and ranks ceramic materials for best clinical performance.

CAD/CAM for dental restorations--some of the curious challenges.

Computer-aided design and manufacturing for dental restorations has opened a new world of possibilities--some that appeal to engineers and clinicians and some that have created some interesting challenges. The objective of this overview is to briefly describe a system being developed by the Universities of Maryland and Minnesota which is capable of producing dental crowns. Some of the challenges and difficulties that have arisen during the development activities will be addressed. The final focus will be on some of the questions that, because of the new technology, can now be addressed and are presenting new challenges.

Confirmation of Leinfelder clinical wear standards.

OBJECTIVES: Accuracy of composite wear studies based on Leinfelder standards has been disputed. There are differences with other well-calibrated systems such as the M-L and Vivadent wear standards. The objective of this study was to reevaluate the margin height at key regions along the restoration margins for each of the 6 Leinfelder standards using laser profiling techniques. METHODS: The Leinfelder standards were profiled in parallel paths 100 microns apart and measured in x-y-z position every 20 microns along those paths using a laser profilometer. RESULTS: Rounding of cavosurface enamel margins from intraoral wear greatly increased the uncertainty of the true enamel margin location and step height measurements, precluding unequivocal measurements for standards #2 and #3. Values for other standards for the original report, newly measured means and standard errors, and measured ranges were: #4 (322 microns, 333 +/- 34 microns, 171-507 microns), #5 (382 microns, 459 +/- 44 microns, 202-649 microns), and #6 (493 microns, 584 +/- 91 microns, 315-1022 microns). There were no statistically significant differences (p < or = 0.10) between these and original values. Large standard errors may have obscured small differences that may exist. The Leinfelder cast conversion scale seems to be the correct relative magnitude. SIGNIFICANCE: Differences between Leinfelder casts and other standards may be due to differences in shadow production. Clinical wear may be systematically underestimated by other cast evaluation methods that have well-defined margins. This emphasizes the need for standard casts with margin morphology similar to the clinical casts being evaluated for wear.

High-technology innovations--and limitations--for restorative dentistry.

Technology has brought some exciting advances to dentistry--restorations that can be produced in one appointment and fit as well as cast restorations; laser procedures that arrest early caries, etch enamel, and that the patient finds more comfortable; and improved diagnostic capabilities through computer-enhanced images. Dental applications of these technologies are in their infancy and most of the limitations discussed in this article will be eliminated in the near future. More and more applications and possibilities are continually evolving. Technology promises to enhance dentistry for the clinician and patient alike.

Force degradation in elastomeric chains.

Elastomeric chains are a frequent choice for delivering forces required to close spaces orthodontically. Unfortunately, these forces degrade over time. Open and closed chains from six orthodontic suppliers were evaluated over time. For both types and for all suppliers, the greatest loss of force occurred within the first hour. During the next 2 to 4 days, forces delivered continued to fall but at a slower rate. Beyond that time, in general, forces delivered remain nearly constant but at a level lower than originally available. The amount of the force delivered at 28 days ranged from 85% to 30% of that available at the time of placement. At 28 days, gray chains from all suppliers delivered forces greater than 100 g.

CAD/CAM in dentistry.

The advent of computers and interactive computer graphics laid the groundwork for a revolution in dentistry. Dental CAD/CAM systems can at least match the quality of cast restorations. With the automation, consistency in quality is also provided. The dental CAD/CAM system can simplify the effort required to produce a restoration. With new technologies for fabrication (like milling and edm), a whole array of new materials, which were historically difficult or impossible to manipulate, suddenly become viable possibilities. When used in the dental office, many of the systems eliminate the need for impressions and can produce a restoration while the patient waits. A dental revolution is underway, providing exciting possibilities for restorative dentistry.

Performance of dental ceramics: challenges for improvements.

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

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

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

Concerns of hydrothermal degradation in CAD/CAM zirconia.

Zirconia-based restorations are widely used in prosthetic dentistry; however, their susceptibility to hydrothermal degradation remains elusive. We hypothesized that CAD/CAM machining and subsequent surface treatments, i.e., grinding and/or grit-blasting, have marked effects on the hydrothermal degradation behavior of Y-TZP. CAD/CAM-machined Y-TZP plates (0.5 mm thick), both with and without subsequent grinding with various grit sizes or grit-blasting with airborne alumina particles, were subjected to accelerated aging tests in a steam autoclave. Results showed that the CAD/CAM-machined surfaces initially exhibited superior hydrothermal degradation resistance, but deteriorated at a faster rate upon prolonged autoclave treatment compared with ground and grit-blasted surfaces. The accelerated hydrothermal degradation of CAD/CAM surfaces is attributed to the CAD/CAM machining damage and the absence of surface compressive stresses in the fully sintered material. Clinical relevance for surface treatments of zirconia frameworks in terms of hydrothermal and structural stabilities is addressed.

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

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