Mechanical properties of bone tissues surrounding dental implant systems with different treatments and healing periods.

OBJECTIVES: The objective of the current study was to examine whether the nanoindentation parameters can assess the alteration of bone quality resulting from different degrees of bone remodeling between bone tissue ages around the dental implant interface with different treatments and healing periods. MATERIALS AND METHODS: Dental implants were placed in mandibles of six male dogs. Treatment groups included: resorbable blast media-treated titanium (Ti) implants, alumina-blasted zirconia implants (ATZ), alumina-blasted zirconia implants applied with demineralized bone matrix (ATZ-D), and alumina-blasted zirconia implants applied with rhBMP-2 (ATZ-B). Nanoindentation modulus (E), hardness (H), viscosity (η), and viscoelastic creep (Creep/P max) were measured for new and old bone tissues adjacent to the implants at 3 and 6 weeks of post-implantation. A total of 945 indentations were conducted for 32 implant systems. RESULTS: Significantly lower E, H, and η but higher Creep/P max were measured for new bone tissues than old bone tissues, independent of treatments at both healing periods (p < 0.001). All nanoindentation parameters were not significantly different between healing periods (p > 0.568). ATZ-D and ATZ-B implants had the stiffer slope of correlation between E and Creep/P max of the new bone tissue than Ti implant (p < 0.039). CONCLUSIONS: Current results indicated that, in addition to elastic modulus and plastic hardness, measurement of viscoelastic properties of bone tissue surrounding the implant can provide more detailed information to understand mechanical behavior of an implant system. CLINICAL RELEVANCE: Ability of energy absorption in the interfacial bone tissue can play a significant role in the long-term success of a dental implant system.

Comparison of the osteogenic potential of titanium- and modified zirconia-based bioceramics.

Zirconia is now favored over titanium for use in dental implant materials because of its superior aesthetic qualities. However, zirconia is susceptible to degradation at lower temperatures. In order to address this issue, we have developed modified zirconia implants that contain tantalum oxide or niobium oxide. Cells attached as efficiently to the zirconia implants as to titanium-based materials, irrespective of surface roughness. Cell proliferation on the polished surface was higher than that on the rough surfaces, but the converse was true for the osteogenic response. Cells on yttrium (Y)/tantalum (Ta)- and yttrium (Y)/niobium (Nb)-stabilized tetragonal zirconia polycrystals (TZP) discs ((Y, Ta)-TZP and (Y, Nb)-TZP, respectively) had a similar proliferative potential as those grown on anodized titanium. The osteogenic potential of MC3T3-E1 pre-osteoblast cells on (Y, Ta)-TZP and (Y, Nb)-TZP was similar to that of cells grown on rough-surface titanium. These data demonstrate that improved zirconia implants, which are resistant to temperature-induced degradation, retain the desirable clinical properties of structural stability and support of an osteogenic response.

Bone formation around zirconia implants combined with rhBMP-2 gel in the canine mandible.

OBJECTIVE: The aim of this study was to estimate the effects of zirconia implants and recombinant human bone morphogenetic protein-2 (rhBMP-2) gel on the acceleration of local bone formation and osseointegration in the canine mandible. MATERIALS AND METHODS: Four groups of 48 implants with identical geometry were installed in the mandibles of beagle dogs: alumina-blasted zirconia implants applied with rhBMP-2, alumina-blasted zirconia implants applied with demineralized bone matrix (DBM), alumina-blasted zirconia implants, and resorbable blast media-treated titanium (Ti) implants. For the first two groups, zirconia implants were inserted after the surgical sites were filled with rhBMP-2 or DBM gel. For the other two groups, zirconia or Ti implants were installed with no adjunctive treatment. Fluorescent bone markers were administered to monitor bone remodeling at weeks 2, 4, and 5 postimplantation. After healing periods of 3 weeks and 6 weeks, the animals were sacrificed, and fluorescent microscopy, histology, and histomorphometric analyses were performed. RESULTS: Fluorescent microscopy showed that bone formation around the zirconia implants installed with rhBMP-2 gel was the most prominent at 2 weeks postimplantation, while the Ti implants acquired bone apposition mainly at week 5. No significant differences were found in bone area among the groups (P > 0.05). The zirconia implants showed similar bone-to-implant contact to the Ti implants. There were no significant differences in bone-to-implant contact between the zirconia implants with rhBMP-2 gel and those with DBM (P > 0.05). CONCLUSIONS: The zirconia implants with alumina-blasted surfaces may achieve osseointegration in much the same manner as the well-established Ti implants. The area influenced by rhBMP-2 gel, including the alveolar crest, may cause active remodeling and early bone formation.

Clinical use of alumina-toughened zirconia abutments for implant-supported restoration: prospective cohort study of survival analysis.

OBJECTIVES: The aim of this prospective cohort study was to compute the long-term clinical survival and complication rates of alumina-toughened zirconia abutments used for implant-supported restorations and to evaluate the effects of several clinical variables on these rates. MATERIAL AND METHODS: From May 1998 to September 2010, 213 patients aged 18 years or older were recruited. The patients received 611 external hex implants and 328 implant-supported fixed restorations using alumina-toughened zirconia abutments. During the follow-up, each restoration was coded as a dental event, which included loosening or fracture of abutment screws, and abutment fracture. From the coded data, the effects of the investigated clinical variables-restored area (anterior/posterior), number of prosthodontic units (one/two units or over), prosthesis type (single-unit/multiunit without pontic/multiunit with pontic), implant system, and patient gender-on the survival of the abutments were evaluated. Survival analysis using Kaplan-Meier method and Cox proportional hazard model was applied. The 5-year survival and complication rates of the abutments were assessed. RESULTS: The number of prosthodontic units and the type of prosthesis had a significant association with complication rates (P < 0.05). Kaplan-Meier survival analysis estimated that the cumulative 5-year complication rate of the abutments used in single restorations was 19.7%. Multiunit-fixed dental prostheses without and with pontics had complication rates of 3.9% and 3.8%, respectively. The 5-year survival rate of the abutments was more than 95%, regardless of the type of prosthesis. CONCLUSIONS: Alumina-toughened zirconia abutments are likely to exhibit excellent long-term survival in clinical use for fixed restorations. Single tooth replacement with the abutment at the molar region may require special care and extra attention.

Comparative analysis on intaglio surface trueness, wear volume loss of antagonist, and fracture resistance of full-contour monolithic zirconia crown for single-visit dentistry under simulated mastication.

PURPOSE: This analysis aimed to evaluate the intaglio surface trueness, antagonist's wear volume loss, and fracture resistance of full-contour crowns of (Y, Nb)-stabilized fully-sintered zirconia (FSZ), 4 mol% or 5 mol% yttria-stabilized partially sintered zirconia (4YZ or 5YZ) with high-speed sintering. MATERIALS AND METHODS: A total of 42 zirconia crowns were separated into three groups: FSZ, 4YZ, and 5YZ (n = 14). The intaglio surface trueness of the crowns was evaluated at the inner surface, occlusal, margin, and axial areas and reported as root-mean-square, positive and negative average deviation. Half of the specimens were aged for 120,000 cycles in the chewing simulator, and the wear volume loss of antagonist was measured. Before and after chewing, the fracture load was measured for each group. The trueness values were analyzed with Welch's ANOVA, and the wear volume loss with the Kruskal-Wallis tests. Effect of the zirconia type and aging on fracture resistance of crowns was tested using two-way ANOVA. RESULTS: The intaglio surface trueness measured at four different areas of the crown was less than 50 µm, regardless of the type of zirconia. No significant P in wear volume loss of antagonists were detected among the groups (P > .05). Both the type of zirconia and aging showed statistically significant effects on fracture resistance (P < .05). CONCLUSION: The full-contour crowns of FSZ as well as 4YZ or 5YZ with high-speed sintering were clinically acceptable, in terms of intaglio surface trueness, antagonist's wear volume loss, and fracture resistance after simulated mastication.

Ceramic Materials and Technologies Applied to Digital Works in Implant-Supported Restorative Dentistry.

Computer-aided design and manufacturing technology has been closely associated with implant-supported restoration. The digital system employed for prosthodontic restorations comprises data acquisition, processing, and manufacturing using subtractive or additive methods. As digital implantology has developed, optical scanning, computer-based digital algorithms, fabricating techniques, and numerical control skills have all rapidly improved in terms of their accuracy, which has resulted in the development of new ceramic materials with advanced esthetics and durability for clinical application. This study reviews the application of digital technology in implant-supported dental restoration and explores two globally utilized ceramic restorative materials: Yttria-stabilized tetragonal zirconia polycrystalline and lithium disilicate glass ceramics.

Enhanced mechanical properties of ZrO2-Al2O3 dental ceramic composites by altering Al2O3 form.

OBJECTIVES: This study evaluates the difference in physical and mechanical properties of ZrO2 ceramics, commonly used in dental applications, altered by three different forms of Al2O3 content; microparticles (m), nanoparticles (n), and microfiber (f). METHODS: Three different types of ZrO2-Al2O3 composites were formed using microparticle (m), nanoparticle (n), or microfibre (f) forms of Al2O3. The physical and mechanical properties such as sintering shrinkage, relative density, Vickers hardness, fracture toughness, and biaxial strength were evaluated. A Weibull analysis was performed to assess the strength reliability of the specimens. All data were calculated using the t-test and ANOVA. RESULTS: The sintering shrinkage and relative density of all ceramic composite groups were decreased with the addition of Al2O3. The mechanical properties of ZrO2-Al2O3 (f) composite were higher than that of ZrO2-Al2O3 (m) composite and ZrO2-Al2O3 (n) composite. The maximum hardness, fracture toughness, and biaxial flexural strength were observed for 10 vol% of Al2O3 fibre. When the content of Al2O3 fibre in the matrix was increased above 20 vol%, agglomeration occurred and resulted in a decrease of hardness and toughness. The Weibull modulus value of the ZrO2-Al2O3 (f) composite was the lowest compared to that of other groups. However, characteristic strength (σ0) of ZrO2-Al2O3 (f) the highest value. SIGNIFICANCE: The current study demonstrated that the addition of right amount of Al2O3 microfibre into the ZrO2 matrix enhanced the mechanical properties of ZrO2-Al2O3 (f) composite, which would be favourable for dental applications.

Trueness of the Inner Surface of Monolithic Crowns Fabricated by Milling of a Fully Sintered (Y, Nb)-TZP Block in Chairside CAD-CAM System for Single-visit Dentistry.

A single-visit zirconia restoration can be easily achieved if direct milling of a fully sintered zirconia block can be performed without much effort. However, no studies have yet been reported regarding the evaluation of the trueness of crown fabricated from chairside-milling of a fully sintered zirconia block in the chairside computer-aided design and computer-aided manufacturing (CAD-CAM) system for single-visit dentistry. This in vitro study aimed to evaluate the trueness of crowns fabricated by milling a fully sintered zirconia block in the chairside CAD-CAM system and investigate the clinical implications for single-visit chairside restoration. Crowns were fabricated either by chairside-milling a fully sintered block of niobium oxide containing yttria-stabilized tetragonal zirconia polycrystals ((Y, Nb)-TZP) without the sintering process (n = 12) in a chairside single-visit dentistry system (Chairside group) or by laboratory-milling a partially sintered 3 mol% block of yttria-stabilized tetragonal zirconia polycrystals (3Y-TZP) followed by the sintering process (n = 12) in a conventional laboratory system (Labside group). Crown fabrication time, milling tool diameter and the trueness of each crown were evaluated. All trueness values of both groups were within the clinically acceptable range, although a significant difference between the Chairside (43.0 ± 3.67 µm) and Labside groups (37.4 ± 2.41 µm) was observed (P < 0.05). Mean fabrication time was 0.52 h and 1.42 h for Chairside and Labside groups, respectively. A decrease in the tool diameter was observed for the Chairside group.

A Prospective Clinical Study of Alumina-Toughened Zirconia Abutments for Implant-Supported Fixed Restorations with a Mean Follow-up Period of 6.9 Years.

PURPOSE: The goal of this study was to compute the estimated cumulative survival and success rates of alumina-toughened zirconia (ATZ) abutments used for external connection-type implant-supported fixed dental prostheses (FDPs) after a mean follow-up of 6.9 years (82.3 months). MATERIALS AND METHODS: From May 1998 to July 2016, patients who provided informed consent and received implant-supported restorations with ATZ abutments were recruited. Clinical performance of zirconia abutments was evaluated using survival analysis. Failure was defined as the removal of the restoration due to zirconia abutment fracture, and complications included both failure and abutment screw problems. Survival and success were the counterparts of failure and complications, respectively. The effects of restoration-related factors (restored area, type of prosthesis, and implant system) on the survival and success of the abutments were estimated. RESULTS: A total of 231 patients were included in this study. One hundred twenty-six implant-supported single-unit and 204 multiple-unit FDPs were evaluated. All the placed implants had the external hex connection. The estimated cumulative 5-year, 7-year, and 10-year survival rates (95% confidence interval [CI]) of zirconia abutment-supported FDPs were 97.3% (95.5% to 99.1%), 96.8% (94.8% to 98.8%), and 94.1% (90.4% to 97.8%), respectively. The estimated cumulative 5-year, 7-year, and 10-year success rates (95% CI) were 94.1% (91.4% to 96.8%), 90.8% (87.3% to 94.3%), and 80.1% (73.6% to 86.6%), respectively. The type of prosthesis (P = .001) and implant system (P < .001) were the significant factors in the success of zirconia abutment-supported FDPs. CONCLUSION: Prefabricated ATZ abutments have a high predictability of survival at 10 years when used in implant-supported FDPs that replace both anterior and posterior teeth. However, the success of zirconia abutments was significantly influenced by the type of prosthesis and implant system.

Analysis of osteogenic potential on 3mol% yttria-stabilized tetragonal zirconia polycrystals and two different niobium oxide containing zirconia ceramics.

PURPOSE: This study was performed to evaluate the osteogenic potential of 3mol% yttria-stabilized tetragonal zirconia polycrystals (3Y-TZP) and niobium oxide containing Y-TZPs with specific ratios, new (Y,Nb)-TZPs, namely YN4533 and YN4533/Al20 discs. MATERIALS AND METHODS: 3Y-TZP, YN4533 and YN4533/Al20 discs (15 mm diameter and 1 mm thickness) were prepared and their average surface roughness (Ra) and surface topography were analyzed using 3-D confocal laser microscope (CLSM) and scanning electron microscope (SEM). Mouse pre-osteoblast MC3T3-E1 cells were seeded onto all zirconia discs and evaluated with regard to cell attachment and morphology by (CLSM), cell proliferation by PicoGreen assay, and cell differentiation by Reverse-Transcription PCR and Quantitative Real-Time PCR, and alkaline phosphatase (Alp) staining. RESULTS: The cellular morphology of MC3T3-E1 pre-osteoblasts was more stretched on a smooth surface than on a rough surface, regardless of the material. Cellular proliferation was higher on smooth surfaces, but there were no significant differences between 3Y-TZP, YN4533, and YN4533/Al20. Osteoblast differentiation patterns on YN4533 and YN4533/Al20 were similar to or slightly higher than seen in 3Y-TZP. Although there were no significant differences in bone marker gene expression (alkaline phosphatase and osteocalcin), Alp staining indicated better osteoblast differentiation on YN4533 and YN4533/Al20 compared to 3Y-TZP. CONCLUSION: Based on these results, niobium oxide containing Y-TZPs have comparable osteogenic potential to 3Y-TZP and are expected to be suitable alternative ceramics dental implant materials to titanium for aesthetically important areas.

Properties and cyclic fatigue of glass infiltrated tape cast alumina cores produced using a water-based solvent.

OBJECTIVE: The purpose of this study was to investigate the properties of tape cast alumina composite produced using a water-based solvent and its possible clinical use as an all ceramic crown system in a fixed partial denture. Durability of the system will be measured by fatigue test to simulate the masticating conditions of the oral cavity. METHODS: The optimal weight ratio of water-based alumina tape was determined by tensile strength, shrinkage ratio and durability. The coefficient of thermal expansion, fracture toughness, biaxial flexural strength and flexural strength after fatigue test of a composite produced from alumina tape at optimal weight ratios were determined and compared to In-Ceram alumina core (control). RESULTS: The weight ratio of alumina/(alumina+binder+plasticizer) of 0.84 and binder/(binder+plasticizer) of 0.5 was observed to be the optimal composition for achieving excellent composite properties. Coefficient of thermal expansion of the sintered alumina tape was observed to be 7.3x10(-6)/degrees C, and this value was increased to 7.5x10(-6)/degrees C after infiltrating the sintered tape with glass. The fracture toughness and biaxial flexural strength of glass infiltrated alumina tape was observed to be 4.6 MPa m(1/2) and 498 MPa, respectively. After cyclic loading for 10(2)-10(6) cycles, no significant change in the biaxial flexural strength was observed between the glass infiltrated alumina core and the In-Ceram alumina core (p>0.05). SIGNIFICANCE: The observed properties provide evidence that the water-based tape cast alumina-glass composite is suitable for clinical use as an all ceramic crown system in a fixed partial denture.

Initial osteoblast-like cell response to pure titanium and zirconia/alumina ceramics.

OBJECTIVES: Outstanding mechanical properties, resistance to scratching and high biocompatibility make zirconia/alumina ceramics interesting for dental applications. To solve the problem of the well-known low temperature degradation and to provide stable mechanical properties a novel zirconia alloy ((Y,Nb)-TZP/alumina) was developed. The aim of this study was to investigate the initial bone cell response to this new zirconia/alumina composite ceramic. METHODS: HOS cells were cultured on zirconia/alumina composite (Zc) and pure titanium (Ti) discs. Surface topography was examined by atomic force microscopy (AFM), cell morphology by scanning electron microscopy (SEM). Cell proliferation (MTS) and alkaline phosphatase activity was measured at 1, 4 and 8 days. The mRNA expression of Cycline D1, the cell cycle regulating gene, integrin beta 1, osteonectin (ON) and beta-actin were evaluated by RT-PCR analysis after 12, 24 and 48 h. RESULTS: Both substrates showed a very smooth character with R(a)-values in the range of 0.002-0.113 microm supporting a continuous cellular growth. After 8 days, cell proliferation on Zc was higher than on Ti. The mRNA expression of cyclin D1 showed similar activity after 48 h on both surfaces, ALP activity was higher on Zc after 8 days. ON expression however showed no difference between the two groups. SIGNIFICANCE: Our data demonstrate that this new zirconia composite ceramic showed at least equivalent or slightly better biological response of osteoblast-like HOS cells than pure titanium during a short-time cell culture period.

Characterization of Human Gingival Fibroblasts on Zirconia Surfaces Containing Niobium Oxide.

It was indicated that tetragonal zirconia polycrystal (TZP) containing yttria (Y2O3) and niobium oxide (Nb2O5) ((Y,Nb)-TZP) could be an adequate dental material to be used at esthetically important sites. The (Y,Nb)-TZP was also proved to possess its osteogenic potential comparable with those conventional dental implant material, titanium (Ti). The objective of the current study was to characterize cellular response of human gingival fibroblasts (HGFs) to smooth and rough surfaces of the (Y,Nb)-TZP disc, which were obtained by polishing and sandblasting, respectively. Various microscopic, biochemical, and molecular techniques were used to investigate the disc surfaces and cellular responses for the experimental (Y,Nb)-TZP and the comparing Ti groups. Sandblasted rough (Y,Nb)-TZP (Zir-R) discs had the highest surface roughness. HGFs cultured on polished (Y,Nb)-TZP (Zir) showed a rounded cell morphology and light spreading at 6 h after seeding and its proliferation rate significantly increased during seven days of culture compared to other surfaces. The mRNA expressions of type I collagen, integrin α2 and ß1 were significantly stimulated for the Zir group at 24 h after seeding. The current findings, combined with the previous results, indicate that (Y,Nb)-TZP provides appropriate surface condition for osseointegration at the fixture level and for peri-implant mucosal sealing at the abutment level producing a suitable candidate for dental implantation with an expected favorable clinical outcome.

Preparation and characterization of nano-sized hydroxyapatite/alginate/chitosan composite scaffolds for bone tissue engineering.

The aim of this study was to develop chitosan composite scaffolds with high strength and controlled pore structures by homogenously dispersed nano-sized hydroxyapatite (nano-HAp) powders. In the fabrication of composite scaffolds, nano-HAp powders distributed in an alginate (AG) solution with a pH higher than 10 were mixed with a chitosan (CS) solution and then freeze dried. While the HAp content increased up to 70 wt.%, the compressive strength and the elastic modulus of the composite scaffolds significantly increased from 0.27 MPa and 4.42 MPa to 0.68 MPa and 13.35 MPa, respectively. Higher content of the HAp also helped develop more differentiation and mineralization of the MC3T3-E1 cells on the composite scaffolds. The uniform pore structure and the excellent mechanical properties of the HAp/CS composite scaffolds likely resulted from the use of the AG solution at pH 10 as a dispersant for the nano-HAp powders.

Efficacy of polyglycolic acid sheet after thoracoscopic bullectomy for spontaneous pneumothorax.

BACKGROUND: Various procedures have been performed to decrease the incidence of recurrent postoperative pneumothorax after thoracoscopic bullectomy. The purpose of this study was to determine the efficacy of a polyglycolic acid (PGA) sheet and pleural abrasion for prevention of recurrent postoperative pneumothorax. METHODS: From January 2009 to August 2011, 257 patients underwent thoracoscopic bullectomy for primary spontaneous pneumothorax. In group A, 128 patients underwent pleural abrasion. These patients were compared with 129 patients (group B) who underwent a procedure to cover stable lines with an absorbable PGA sheet in addition to pleural abrasion. RESULTS: There was no difference in preoperative demographics, although the age of patients in group A was statistically higher than that of patients in group B (23.67 ± 6.54 versus 21.69 ± 5.65; p = 0.010). In group A, prolonged postoperative air leaks (≥ 3 days) occurred more frequently (7.8% versus 2.3%; p = 0.045). A Kaplan-Meier curve showed that recurrence-free rates were higher in group B (p = 0.047). CONCLUSIONS: Coverage with PGA sheet and pleural abrasion after thoracoscopic bullectomy is effective for preventing prolonged postoperative air leaks and reducing postoperative recurrence rates.

Initial in vitro bacterial adhesion on dental restorative materials.

OBJECTIVES: The purpose of this study was to evaluate initial bacterial adhesion on several restorative materials with similar roughness. MATERIALS AND METHODS: Sixty cylindrical slabs were prepared from four restorative materials: zirconia (Zr), alumina-toughened zirconia (Al-Zr), type III gold alloy (Au), and cp-titanium (Ti). All the materials were polished until a mirror-like shine was achieved. The average surface roughness and topography were determined by atomic force microscopy. Contact angles were measured to calculate surface free energy by the sessile drop technique. After the formation of a salivary pellicle, S. sanguinis, S. gordonii, and S. oralis were inoculated onto the specimens and incubated for 4 h. Quantification of the adherent bacteria was performed by crystal violet staining technique and resazurin reduction assay. One-way ANOVA and Tukey's post hoc test were adopted for statistical analysis. The level of significance was 0.05. RESULTS: The Ra values determined with atomic force microscopy for all specimens were lower than 5 nm. Surface free energy increased in the order of Al-Zr, Zr, Ti, and Au. Differences were significant between the investigated materials in both crystal violet absorbance and fluorescence intensities. Gold alloy showed the highest values for all bacterial strains (p<0.05). CONCLUSIONS: Zirconia, alumina-toughened zirconia, and titanium may be more suitable than gold alloy as an abutment material with respect to the initial bacterial adhesion and subsequent advance of peri-implantitis.

Influence of processing parameters on pore structure of 3D porous chitosan-alginate polyelectrolyte complex scaffolds.

Fabrication of porous polymeric scaffolds with controlled structure can be challenging. In this study, we investigated the influence of key experimental parameters on the structures and mechanical properties of resultant porous chitosan-alginate (CA) polyelectrolyte complex (PEC) scaffolds, and on proliferation of MG-63 osteoblast-like cells, targeted at bone tissue engineering. We demonstrated that the porous structure is largely affected by the solution viscosity, which can be regulated by the acetic acid and alginate concentrations. We found that the CA PEC solutions with viscosity below 300 Pa.s yielded scaffolds of uniform pore structure and that more neutral pH promoted more complete complexation of chitosan and alginate, yielding stiffer scaffolds. CA PEC scaffolds produced from solutions with viscosities below 300 Pa.s also showed enhanced cell proliferation compared with other samples. By controlling the key experimental parameters identified in this study, CA PEC scaffolds of different structures can be made to suit various tissue engineering applications.