Impurities in commercial titanium dental implants - A mass and optical emission spectrometry elemental analysis.

OBJECTIVE: Titanium (Ti) is considered bioinert and is still regarded as the "gold standard" material for dental implants. However, even 'commercial pure' Ti will contain minor fractions of elemental impurities. Evidence demonstrating the release of Ti ions and particles from 'passive' implant surfaces is increasing and has been attributed to biocorrosion processes which may provoke immunological reactions. However, Ti observed in peri-implant tissues has been shown to be co-located with elements considered impurities in biomedical alloys. Accordingly, this study aimed to quantify the composition of impurities in commercial Ti dental implants. METHODS: Fifteen commercial titanium dental implant systems were analyzed using inductively coupled plasma-mass spectrometry (ICP-MS) and optical emission spectrometry (ICP-OES). RESULTS: The elemental composition of implants manufactured from commercially pure grades of Ti, Ti-6Al-4V, and the TiZr alloy (Roxolid) conformed to the respective ISO/ASTM standards or manufacturers´ data (TiZr/Roxolid). However, all implants investigated included exogenous metal contaminants including Ni, Cr, Sb, and Nb to a variable extent. Other contaminants detected in a fraction of implants included As and the radionuclides U-238 and Th-232. SIGNIFICANCE: Although all Ti implant studies conformed with their standard compositions, potentially allergenic, noxious metals and even radionuclides were detected. Since there are differences in the degree of contamination between the implant systems, a certain impurity fraction seems technically avoidable. The clinical relevance of these findings must be further investigated, and an adaptation of industry standards should be discussed.

Reducing MRI susceptibility artefacts in implants using additively manufactured porous Ti-6Al-4V structures.

Magnetic Resonance Imaging (MRI) is critical in diagnosing post-operative complications following implant surgery and imaging anatomy adjacent to implants. Increasing field strengths and use of gradient-echo sequences have highlighted difficulties from susceptibility artefacts in scan data. Artefacts manifest around metal implants, including those made from titanium alloys, making detection of complications (e.g. bleeding, infection) difficult and hindering imaging of surrounding structures such as the brain or inner ear. Existing research focusses on post-processing and unorthodox scan sequences to better capture data around these devices. This study proposes a complementary up-stream design approach using lightweight structures produced via additive manufacturing (AM). Strategic implant mass reduction presents a potential tool in managing artefacts. Uniform specimens of Ti-6Al-4V structures, including lattices, were produced using the AM process, selective laser melting, with various unit cell designs and relative densities (3.1%-96.7%). Samples, submerged in water, were imaged in a 3T MRI system using clinically relevant sequences. Artefacts were quantified by image analysis revealing a strong linear relationship (RR2 = 0.99) between severity and relative sample density. Likewise, distortion due to slice selection errors showed a squared relationship (RR2 = 0.92) with sample density. Unique artefact features were identified surrounding honeycomb samples suggesting a complex relationship exists for larger unit cells. To demonstrate clinical utility, a honeycomb design was applied to a representative cranioplasty. Analysis revealed 10% artefact reduction compared to traditional solid material illustrating the feasibility of this approach. This study provides a basis to strategically design implants to reduce MRI artefacts and improve post-operative diagnosis capability. STATEMENT OF SIGNIFICANCE: MRI susceptibility artefacts surrounding metal implants present a clinical challenge for the diagnosis of post-operative complications relating to the implant itself or underlying anatomy. In this study for the first time we demonstrate that additive manufacturing may be exploited to create lattice structures that predictably reduce MRI image artefact severity surrounding titanium alloy implants. Specifically, a direct correlation of artefact severity, both total signal loss and distortion, with the relative material density of these functionalised materials has been demonstrated within clinically relevant MRI sequences. This approach opens the door for strategic implant design, utilising this structurally functionalised material, that may improve post-operative patient outcomes and compliments existing efforts in this area which focus on data acquisition and post-processing methods.

Glass ionomer cements with milled, dry chlorhexidine hexametaphosphate filler particles to provide long-term antimicrobial properties with recharge capacity.

OBJECTIVE: Glass ionomer cements (GICs) are a versatile material, offering the opportunity for ion exchange with the oral environment. The aim of this study was to develop a GIC that delivers a controlled, rechargeable dose of chlorhexidine (CHX) over an extended period without compromising mechanical properties. METHODS: GICs were supplemented with finely milled particles of chlorhexidine hexametaphosphate (CHX-HMP). CHX release into artificial saliva was measured over 660 days, and recharge with CHX and CHX-HMP was investigated. Mechanical properties were investigated, and an agar diffusion test was carried out to assess antimicrobial properties using Streptococcus mutans and Scardovia wiggsiae. RESULTS: Dose-dependent CHX release was observed, and this was ongoing at 660 days. Compared with related studies of GICs containing CHX-HMP, the fine, dry particles resulted in fewer adverse effects on mechanical properties, including tensile, compressive and biaxial flexural strength, with 1% CHX-HMP GICs indistinguishable from control specimens. The GICs could be recharged with CHX using both a conventional CHX digluconate solution comparable to commercial mouthrinses, and a suspension of CHX-HMP of equivalent concentration. Recharging with CHX digluconate increased subsequent CHX release by 50% compared with no recharge, and recharging with CHX-HMP increased subsequent CHX release by 100% compared with no recharge. The GICs inhibited growth of St. mutans and Sc. wiggsiae in a simple agar diffusion model. SIGNIFICANCE: These materials, which provide sustained CHX release over clinically relevant timescales, may find application as a restorative material intended to inhibit secondary caries as well as in temporary restorations and fissure sealants.

The strength of sintered and adhesively bonded zirconia/veneer-ceramic bilayers.

OBJECTIVES: Recently all-ceramic restorative systems have been introduced that use CAD/CAM technology to fabricate both the Y-TZP core and veneer-ceramic layers. The aim was to identify whether the CAD/CAM approach resulted in more favourable stressing patterns in the veneer-ceramic when compared with a conventionally sintered Y-TZP core/veneer-ceramic. METHODS: Nominally identical Vita VM9 veneer-ceramic disc-shaped specimens (0.7mm thickness, 12mm diameter) were fabricated. 20 specimens received a surface coating of resin-cement (Panavia 21); 20 specimens were bonded with the resin-cement to fully sintered Y-TZP (YZ Vita Inceram Vita) discs (0.27mm thickness, 12mm diameter). A final series of 20 Y-TZP core/veneer-ceramic specimens were manufactured using a conventional sintering route. Biaxial flexure strength was determined in a ball-on-ring configuration and stress at the fracture origin calculated using multilayer closed-form analytical solutions. Fractography was undertaken using scanning electron microscopy. The experimental test was simulated using Finite Element Analysis. Group mean BFS were compared using a one-way ANOVA and post hoc Tukey tests at a 95% significance level. RESULTS: Resin cement application resulted in significant strengthening of the veneer-ceramic and further significant strengthening of the veneer-ceramic (p<0.01) occurred following bonding to the Y-TZP core. The BFS calculated at the failure origin for conventionally sintered specimens was significantly reduced when compared with the adhesively bonded Y-TZP/veneer-ceramic. CONCLUSIONS: Under the test conditions employed adhesive cementation between CAD/CAM produced Y-TZP/veneer-ceramic layers appears to offer the potential to induce more favourable stress states within the veneer-ceramic when compared with conventional sintered manufacturing routes. CLINICAL SIGNIFICANCE: The current investigation suggests that the stressing patterns that arise in all-ceramic restorations fabricated using CAD/CAM for both the core and veneer-ceramic layers differ from those that occur in conventionally sintered bilayer restorations. Further work is required to ascertain whether such differences will translate into improved clinical outcomes.

Atmospheric moisture effects on the testing rate and cementation seating load following resin-strengthening of a soda lime glass analogue for dental porcelain.

OBJECTIVES: To investigate if resin-cementation of a soda lime glass dental analogue could elucidate information regarding the pattern of resin-reinforcement when coated in an environment actively scavenged of moisture. METHODS: 192 soda lime disc-shaped specimens (alumina particle air abraded, hydrofluoric acid-etched and silane coated) were randomly assigned to eight groups (n=24 per group) prior to resin-coating at seating loads of 5 N (Groups A-D) and 30 N (Groups E-H) in an environment where moisture was actively scavenged and maintained below 15 ppm. Following one week storage the discs were tested in biaxial flexure at crosshead rates of 0.01, 0.1, 1 and 10mm/min. Analysis of group means was performed utilising a general linear model univariate analysis and post hoc all paired Tukey tests (P<0.05). RESULTS: The general linear model univariate analysis identified the mean biaxial flexure strength (BFS) was significantly influenced by the factors resin-cementation seating load (P<0.001) and crosshead speed of the applied load (P<0.001) with a significant interaction (P=0.008) between both factors. The linear logarithmic regression curves fitted to the group mean BFS data plotted against the crosshead speed highlighted significant differences between the pattern of resin-strengthening for the cementation loads and testing conditions. CONCLUSIONS: The decrease in resin-penetration expected within the 'resin-ceramic hybrid layer' following removal of the 30 N seating load was proposed as the modifying resin-strengthening parameter. These observations are supported by the viscoelastic and creep behaviour of resins at slow testing rates which becomes the dominant or determining phenomenon.

Testing rate and cementation seating load effects on resin-strengthening of a dental porcelain analogue.

OBJECTIVES: To determine the resin-strengthening dependence of a soda-lime-glass analogue for dental porcelain as a function of biaxial flexure strength (BFS), test crosshead rate and cementation seating load. METHODS: Disc-shaped soda-lime glass specimens were divided into twelve groups (n=24), alumina particle air abraded and hydrofluoric acid-etched. Specimens (Groups A-D) were stored in a desiccator prior to testing at crosshead rates of 0.01, 0.1, 1 and 10mm/min, respectively. The remaining specimens were silane treated, Rely-X Veneer resin-coated with a seating load of 5N (Groups E-H) and 30N (Groups I-L) prior to light irradiation at 480±20mW/cm(2), 24h dry storage and BFS testing at 0.01, 0.1, 1 and 10mm/min, respectively. A linear logarithmic regression curve was fit to the raw data to elucidate static fatigue effects of the soda-lime-glass. Analysis of group means was performed utilising a general linear model univariate analysis and post hoc all paired Tukey tests (P<0.05). RESULTS: The linear logarithmic regression curve demonstrated the static fatigue effects of the soda-lime-glass analogue. Rely-X Veneer resin-coating (Groups E-L) resulted in significant increases in the mean BFS data for all crosshead rates examined (all P<0.001). However, the pattern of rate dependence effects on resin-cementation deviated from the log relationship observed with the uncoated controls. CONCLUSION: This study further highlights that when slow crack growth is simulated during testing, valuable insights into the significant modification of a hereto well described phenomenon such as resin-strengthening mediated by the resin-ceramic hybrid layer is provided.

Can a soda-lime glass be used to demonstrate how patterns of strength dependence are influenced by pre-cementation and resin-cementation variables?

OBJECTIVES: To determine how the variability in biaxial flexure strength of a soda-lime glass analogue for a PLV and DBC material was influenced by precementation operative variables and following resin-cement coating. METHODS: The flexural modulus of a transparent soda-lime glass was determined by longitudinally sectioning into rectangular bar-shaped specimens and the flexural moduli of three resin-based materials (Venus Flow, Rely-X Veneer and Clearfil Majesty Posterior) was also determined. Disc shaped soda-lime glass specimens (n=240) were divided into ten groups and were alumina particle air abraded, hydrofluoric (HF) acid-etched and resin-cement coated prior to biaxial flexure strength testing. Sample sets were profilometrically evaluated to determine the surface texture. One-way analyses of variance (ANOVA) and post hoc all paired Tukey tests were performed at a significance level of P<0.05. The mean biaxial flexure strengths were plotted against resin-coating thickness and a regression analysis enabled estimation of the 'actual' magnitude of strengthening. RESULTS: The mean three-point flexural modulus of the soda-lime glass was 40.0 (1.0)GPa and the Venus Flow, Rely-X Veneer and Clearfil Majesty Posterior were 3.0 (0.2)GPa, 6.0 (0.2)GPa and 14.8 (1.6)GPa, respectively. At a theoretical 'zero' resin-coating thickness an increase in biaxial flexure strength of 20.1% (63.2MPa), 30.8% (68.8MPa) and 36.3% (71.7MPa), respectively was evident compared with the control (52.6 (5.5)MPa). CONCLUSIONS: Disc-shaped specimens cut from round stock facilitated rapid fabrication of discs with uniform surface condition and demonstrated strength dependence was influenced by precementation parameters and resin-cementation variables.

Improved bonding of zirconia substructures to resin using a "glaze-on" technique.

OBJECTIVE: To investigate the influence of applying thin intermediary coatings of acid-etchable glasses on the shear bond strength between a methacrylate resin based cement and an yttria-stabilized zirconia dental ceramic substrate. METHODS: The upper and lower surfaces of 110 sintered yttria-stabilised tetragonal zirconia polycrystalline disc-shaped specimens were polished using sequential grades of Silicon Carbide, then air-abraded with 25 µm diameter alumina particles. Specimens were randomly allocated to 11 groups (A-K) (n=10), group A acting as control. The upper surface of Group A specimens was subjected to a tribochemical coating regime (CoJet, 3M ESPE). Five glazing ceramics were applied and fired according to the manufacturer's recommended firing regime. The glaze was etched with 10% HF acid and all specimens coated with a silane primer. Two differing storage regimes were employed (wet storage vs thermocycling). Shear bond strength testing specimens were created by cementing resin-based composite cylinders to the centre of the prepared ceramic surface using Rely-X Unicem (3M ESPE) resin based cement. Shear bond strength testing was performed and load at failure recorded. RESULTS: A factorial analysis of variance at a 95% significance level demonstrated that all glazing techniques resulted in a significant increase in the shear bond strength compared with using the resin based cement alone (P<0.01), with the different glazing ceramics resulting in significant differences in mean shear bond strength (P=0.008). The differences were a function of the storage state (wet storage vs thermocycling (P=0.013)). CONCLUSION: The glazing techniques used in the current investigation resulted in a significantly enhanced shear bond stress to the resin based cement when compared with the current 'gold standard' - tribochemical coating.

Application of analytical stress solutions to bi-axially loaded dental ceramic-dental cement bilayers.

OBJECTIVE: Increased consideration of dental ceramics and dental cements as a singular structural unit for in-vitro mechanical testing has resulted in the reporting of a wide range of analytical methods to calculate the failure stresses. Therefore a comparison of observations between studies is complicated by the use of dissimilar stress solutions despite the employment of a similar testing methodology and specimen geometry. MATERIALS AND METHODS: Three analytical solutions to calculate failure stresses in bi-axially loaded dental ceramic-dental cement bilayers were appraised for a commonly utilized testing geometry (ball-on-ring). Clinically relevant datasets were generated from the bi-axial flexure testing of uncoated and dental cement coated aluminous core ceramic exposed to differing ceramic surface preparations. A Weibull statistical approach was utilized in order to provide insight into the impact of the analytical method on both the scale (sigma0) and distribution (m) of the failure stress data. RESULTS: Calculation of the bi-axial flexure stress utilizing Timoshenko's analysis resulted in an increase in sigma0 for the uncoated (6%) and dental cement coated (11-12%) aluminous core ceramic, when compared with the bilayered solutions reported by Rosenstiel and Hsueh. However, the shape of the failure distributions illustrated by the consistency of m and associated 95% confidence intervals was not influenced by the analytical stress solution employed. SIGNIFICANCE: The choice of the analytical method chosen to calculate failure stresses in bi-axially loaded dental ceramic-dental cement bilayers will impact on the magnitude of the reported strength. Comparison between the failure stresses of uncoated and cement coated dental ceramics is more accurately represented by bilayer solutions, which account for the mismatch between the elastic constants of dissimilar materials. However, within the context of dental cement coated dental ceramics of clinically relevant dimensions, the choice of solution is unlikely to impact on the interpretation of the observations previously reported in the dental literature.

The impact of modifying alumina air abrasion parameters on the fracture strength of a porcelain laminate restorative material.

OBJECTIVES: The modification of the "fit" surface of porcelain laminate veneer restorations in order to improve adhesion prior to cementation is often indiscriminate. As a consequence, the surface flaw distribution which is implicated in the probability of failure of the restoration is likely to be dramatically modified. The purpose of the current study was to examine the impact of different air abrasion surface treatments on the bi-axial flexure strength and surface roughness of a porcelain restorative material. METHODS: Sets of 30 Vitadur-Alpha dentin porcelain discs (15 mm diameter, 0.9 mm thickness) were alumina abraded with three different grades of alumina particle (25, 50 and 110 microm), utilizing two different air stream pressures (35 and 70 psi) and two distinct angles of incidence of particle delivery (45 degrees and 90 degrees ). Mean bi-axial flexure strengths, standard deviations, the associated Weibull moduli (m) and characteristic stress were determined using bi-axial flexure (ball on ring). RESULTS: A univariate general linear analysis of means revealed a significant difference between the mean bi-axial flexure strength values of the control group and those of groups subjected to alumina particle air abrasion. Further significance (P<0.05) was discovered with the impact of alumina particle size and the interaction between particle size and angle of incidence of particle delivery. The reliability of the fracture strength data generally improved when 50 microm alumina particles were used whereas discontinuities existed at lower strength values when 25 and 110 microm alumina particles were employed. CONCLUSIONS: Alumina particle air abrasion has a significant degradative effect on the bi-axial flexure strength of the porcelain disc-shaped specimens. Variation of alumina size, delivery pressure and angle of particle delivery all impacted on the degree of strength reduction and the shape of the survival probability distributions. It is suggested that alumina particle air abrasion acts to remove/modify the initial flaw distribution replacing it with flaws of differing geometry and stability. The premature failure of porcelain laminate restorations may be markedly influenced by alumina particle air abrasion depending upon the size and distribution of the crystalline phase present in different dentine porcelains materials used in construction of the restoration.

The influence of cement lute, thermocycling and surface preparation on the strength of a porcelain laminate veneering material.

OBJECTIVES: The purpose of the current study was to examine the impact of thermocycling on the development of surface flaws on the cemented surfaces of PLV restorations prepared by acid-etching or alumina (Al2O3) abrasion. METHODS: Sets of 30 Vitadur-alpha dentin porcelain discs (15 mm diameter, 0.9 mm thickness) were prepared by either abrading with 50 microm Al2O3 or hydrofluoric (HF) acid-etching. Further specimen series were coated with a resin luting cement prior to thermocycling to simulate the conditions encountered 'in service'. Mean fracture strengths, standard deviations and associated Weibull moduli (m) were determined using bi-axial fracture (ball-on-ring). RESULTS: The two-way ANOVA revealed significant differences between the mean strength values of the porcelain specimens abraded with 50 microm Al2O3 compared with the higher strength HF acid-etched specimens. Significant differences were also identified in the mean fracture strength data for the abraded cemented and acid-etched cemented groups with the abraded groups recording the highest strength levels. SIGNIFICANCE: Composite resin polymerisation shrinkage may help to strengthen porcelain surfaces by imposing a compressive stress on the porcelain surface. However, the strength of the HF etched cemented groups when bonded to composite resin were weaker than abraded specimens. Etching the porcelain does not only provide the necessary surface roughness conducive to mechanical interlocking but would appear to have a weakening effect on the porcelain surfaces.