Influence of dentin and enamel on the fracture resistance of restorations at several thicknesses.

PURPOSE: To investigate the effect of substrate and thickness on the fracture resistance of bonded dental restorative materials. METHODS: Cylindrical restorations (d = 4.0 mm) of resin composites Filtek Supreme XTE, Clearfil AP-X, Lava Ultimate and glass-ceramic IPS e.max CAD were fabricated at thicknesses of 0.5 mm, 1.0 mm and 2.0 mm respectively (n = 10 per group) and adhesively bonded to bovine enamel or dentin. The load to failure (LtF in N) of all specimens was determined in a universal testing machine and two one-way ANOVAs with a post hoc LSD tests and separate independent samples t-tests, performed at a significance level of 5%. RESULTS: At 0.5 and 1.0 mm, direct resin composites bonded to dentin showed a higher LtF than when bonded to enamel, while the indirect materials showed reversed results (P< 0.05). At 2.0 mm there was no difference except for LU. A direct relationship between LtF and increasing thicknesses on enamel was found, while on dentin the LtF of direct resin composite restorations was less dependent on the thickness. CLINICAL SIGNIFICANCE: For restorations up to 1 mm thickness, a substrate with a matching elastic modulus has a positive effect on the fracture resistance of glass-ceramics and resin composite restorations. When bonded to enamel, restoration thickness plays an important role in the fracture resistance. When bonded to dentin, thickness only affects the fracture resistance of indirect restoratives.

Thickness and Substrate Effect on the Mechanical Behaviour of Direct Occlusal Veneers.

PURPOSE: This study aimed to evaluate the fracture resistance and stress magnitude of occlusal veneers made of conventional or flowable resin composites at different minimal thicknesses bonded on enamel or dentin. MATERIAL AND METHODS: A total of 120 sound bovine incisors were flattened and used as substrates (enamel or dentin) for the restorations. The teeth were embedded into polymethyl methacrylate and allocated into 4 groups according to the resin composite (Clearfil AP-X PLT and Clearfil Majesty Flow, Kuraray Dental) and substrate. Further, the substrates were randomly subdivided in 12 groups (N = 120, n = 10) according to the occlusal veneer minimal thickness: 0.5, 1.0, or 2.0 mm. The teeth were directly restored with a standardised procedure. Then, the specimens were loaded until fracture in a universal testing machine (Instron 6022, Instron Corp.). A 3-way and a 1-way analysis of variance were used to determine significant differences for each factor. Three-dimensional finite element analysis was carried out following the in vitro boundary conditions to assess the stress magnitude in the restoration during compressive loading. RESULTS: The fracture loads were recorded into initial load to failure (ILF) and fatal load to failure (FLF). Differences were found in material for ILF and FLF, leading to an overall equal good performance in fracture load and stress distribution for both materials, regardless of the substrate. Differences in thickness were apparent in both ILF and FLF. CONCLUSIONS: Direct conventional and flow resin composite occlusal veneers present a promising mechanical behaviour when bonded on enamel or dentin. However, caution is advised when preparing 0.5-mm minimal thickness restorations.

In vitro fracture resistance of fiber reinforced cusp-replacing composite restorations.

OBJECTIVES: To assess the fracture resistance and failure mode of fiber reinforced composite (FRC) cusp-replacing restorations in premolars. METHODS: Forty-five extracted sound upper premolars were randomly divided into three groups. Identical MOD cavities with simulated buccal cusp fracture and height reduction of the palatal cusp were prepared. In Group A two layers of resin impregnated woven continuous FRC (EverStick Net) were applied. In Group B one layer of unidirectional continuous FRC (EverStick) was used. In Group C no fibers were applied (control). Subsequently, all teeth were restored with resin composite (Clearfil Photo Posterior), subjected to thermocycling (6000 x 5-55 degrees C) and static load tests. Load until fracture was registered for each tooth. Simultaneously, fracture propagation was monitored using acoustic emission analysis (AE). Failure modes were visually assessed. RESULTS: Weibull analysis revealed a characteristic strength and Weibull modulus (m) at 2364.8 N for Group A (m=8.9), 2437.9 N for Group B (m=5.9) and 2160.3N for Group C (m=13.6). Fracture loads were not significantly different (ANOVA, p>0.05). Teeth with FRC showed less fractures below the cemento-enamel junction (CEJ) (38% and 23% for Groups A and B, respectively) than teeth without FRC (93%) (chi-square, p<0.05). The control group showed the least AE energy signals. SIGNIFICANCE: The results suggest that glass FRC does not increase fracture load of premolars with cusp-replacing restorations. However, FRC has a beneficial effect on the failure mode. Woven fibers give more consistent results than unidirectional fibers.

Fracture strength of cusp replacing resin composite restorations.

PURPOSE: To assess the influence of an additional shoulder preparation on the fracture strength of a cusp-replacing direct resin composite restoration in a premolar that previously had an amalgam MOD restoration followed by fracture of a cusp. MATERIALS AND METHODS: Two preparation designs were tested. In extracted sound premolars an MOD amalgam cavity was simulated followed by fracture of a cusp (Group A). Group B was the same as Group A but a shoulder was added along the cervical outline of the preparation. As a control group, cusp fracture was simulated but no MOD amalgam cavities were prepared. For each group, 14 preparations were made using a copy milling technique. All 42 preparations were restored using a direct resin composite restoration technique. Restorations were loaded until fracture. RESULTS: The fracture strength of the preparation with shoulder was not significantly different from the preparation without the shoulder. The fracture strength of the preparations in the reference group, which had no resistance form, was significantly less than in Groups A and B (ANOVA, P<0.05).

A randomized clinical trial of cusp-replacing resin composite restorations: efficiency and short-term effectiveness.

PURPOSE: This study aimed to assess the efficacy and short-term effectiveness of the morphology and function of direct and indirect cusp-replacing resin composite restorations. MATERIALS AND METHODS: In 94 patients, 106 cusp-replacing restorations for maxillary premolars were fabricated to restore Class II caries lesions with 1 cusp missing. Fifty-four direct (Clearfil AP-X) and 52 indirect (Estenia) resin composite restorations were placed following a strict protocol. The treatment technique and operator were assigned randomly. Treatment time was recorded for all restorations. One-month postoperative evaluation included assessment of postoperative sensitivity and presence of occlusal and proximal contacts. RESULTS: Treatment time for the indirect technique (68 +/- 17 min) was longer than for the direct technique (45 +/- 13 min). Regression analysis revealed that the restorative method, operator, and location of the preparation outline had a statistically significant effect on the total treatment time. Occlusal contacts were observed in 94% of the direct restorations and in 98% of the indirect restorations (chi-square, P>.05). Mesial proximal contacts were present in 98% of the direct and in 97% of the indirect restorations (chi-square, P > .05). Distal contacts were present in 100% of the restorations for both techniques. Postoperative sensitivity within 1 week posttreatment was reported for 11% of the direct restorations and for 13% of the indirect restorations, but decreased to 4% and 6%, respectively, after 1 month (chi-square, P > .05). CONCLUSION: The results of this study suggest that in the short term, both direct and indirect adhesive techniques are adequate to restore the morphology and function of premolars presenting with Class II caries lesions and a missing cusp.

Fatigue resistance of teeth restored with cuspal-coverage composite restorations.

PURPOSE: This study assessed the influence of palatal cuspal coverage on the in vitro fatigue resistance and failure mode of Class II resin composite restorations including replacement of the buccal cusp in premolars. MATERIALS AND METHODS: A master model was made of a maxillary premolar with an MOD amalgam cavity and a simulated fracture of the buccal cusp from the isthmus floor to the CEJ. Using a copy-milling machine, this preparation was copied to 20 extracted human maxillary premolars (group A). Subsequently, the palatal cusp was reduced by 1.5 mm; this modified preparation was copied to 20 additional maxillary premolars (group B). Direct resin composite restorations were made in all teeth. Cyclic load (5 Hz) was applied, starting with a load of 200 N (10,000 cycles), followed by stages of 400, 600, 800, and 1,000 N at a maximum of 50,000 cycles each. Samples were loaded until fracture or to a maximum of 210,000 cycles. RESULTS: Of the restored premolars of group A, 20% withstood all 210,000 loading cycles; in group B, this figure was 55%. In group A, 19% of the fractures ended below the CEJ; in group B, 78% did. CONCLUSION: Palatal cuspal coverage increased the fatigue resistance of Class II resin composite restorations with replacement of the buccal cusp in premolars. However, fractures of restorations with cuspal coverage led to more dramatic failures that made restoration virtually impossible. This suggests caution in lowering remaining cusps for these adhesive restorations in the clinical situation.

A survey of cusp fractures in a population of general dental practices.

PURPOSE: This study was conducted to expand the knowledge on the incidence of complete cusp fractures of posterior teeth in Dutch general practices. MATERIALS AND METHODS: During a 3-month period, data were obtained from 28 general practitioners, representing 46,394 patients. For each new case of complete cusp fracture, clinicians recorded information using a standard form with questions relating to location of the fracture, cause of fracture, and restorative status of the tooth prior to the cusp fracture. RESULTS: There were 238 cases of complete cusp fracture recorded. The results of this study indicate an incidence rate of cusp fractures of 20.5 per 1,000 person-years at risk. Molars were more frequently registered with cusp fractures than premolars (79% vs 21%). Maxillary molars presented more fractures of buccal cusps (66% vs 34%), while mandibular molars presented more fractures of lingual cusps (75% vs 25%). Almost 77% of the cases had been restored on three or more surfaces. Statistical analysis revealed a positive correlation between history of endodontic treatment and subgingival fracture location. Mastication was most frequently reported as the cause for fracture (54%), although one can argue whether the occlusal force was the cause or the immediate reason. CONCLUSION: This study revealed that complete cusp fracture is a common phenomenon in dental practice and has shown differences in cusp fracture with respect to tooth type and restorative status of the tooth. Teeth with a history of endodontic treatment are susceptible to unfavorable subgingival fracture locations.