A time slice analysis of dentistry students' visual search strategies and pupil dilation during diagnosing radiographs.

Diagnosing orthopantomograms (OPTs: panoramic radiographs) is an essential skill dentistry students acquire during university training. While prior research described experts' visual search behavior in radiology as global-to-focal for chest radiographs and mammography, generalizability to a hybrid search task in OPTs (i.e., searching for multiple, diverse anomalies) remains unclear. Addressing this gap, this study investigated visual search of N = 107 dentistry students while they were diagnosing anomalies in OPTs. Following a global-to-focal expert model, we hypothesized that students would use many, short fixations representing global search in earlier stages, and few, long fixations representing focal search in later stages. Furthermore, pupil dilation and mean fixation duration served as cognitive load measures. We hypothesized that later stages would be characterized by elaboration and a reflective search strategy, leading to higher cognitive load being associated with higher diagnostic performance in late compared to earlier stages. In line with the first hypothesis, students' visual search comprised of a three-stage process that grew increasingly focal in terms of the number of fixations and anomalies fixated. Contrary to the second hypothesis, mean fixation duration during anomaly fixations was positively associated with diagnostic performance across all stages. As OPTs greatly varied in how difficult it was to identify the anomalies contained therein, OPTs with above-average difficulty were sampled for exploratory analysis. Pupil dilation predicted diagnostic performance for difficult OPTs, possibly capturing elaborative cognitive processes and cognitive load compared to mean fixation duration. A visual analysis of fine-grained time slices indicated large cognitive load differences towards the end of trials, showcasing a richness-resolution-trade-off in data sampling crucial for future studies using time-slicing of eye tracking data.

Shear Wave Elastography in Bruxism-Not Yet Ready for Clinical Routine.

Ultrasound shear wave elastography (SWE) is an emerging modality for the estimation of stiffness, but it has not been studied in relation to common disorders with altered stiffness, such as bruxism, which affects almost one-third of adults. Because this condition could lead to an increased stiffness of masticatory muscles, we investigated SWE in bruxism according to a proof-of-principle and feasibility study with 10 patients with known bruxism and an age- and gender-matched control group. SWE of the left and right masseter muscles was estimated under three conditions: relaxed jaw, 50% of the subjective maximal bite force, and maximal jaw opening. Rejecting the null hypothesis, SWE was significantly increased during relaxed jaw (bruxism 1.92 m/s ± 0.44; controls 1.66 m/s ± 0.24), whereas for maximal mouth opening, the result was vice versa increased with 2.89 m/s ± 0.93 for bruxism patients compared with 3.53 m/s ± 0.95 in the healthy control, which could be due to limited jaw movement in chronic bruxism patients (bruxism 4.46 m/s ± 1.17; controls 5.23 m/s ± 0.43). We show that SWE in bruxism is feasible and could be of potential use for diagnostics and monitoring, though we also highlight important limitations and necessary methodological considerations for future studies.

Trueness and precision of skin surface reproduction in digital workflows for facial prosthesis fabrication.

STATEMENT OF PROBLEM: How much skin surface details of facial prostheses can be transferred throughout the digital production chain has not been quantified. PURPOSE: The purpose of this in vitro study was to quantify the amount of skin surface details transferred from the prosthesis virtual design through the prototype printing with various additive manufacturing (AM) methods to the definitive silicone prosthesis with an indirect mold-making approach. MATERIAL AND METHODS: Twelve test blocks with embossed wrinkles of 0.05 to 0.8 mm and 12 test blocks with applied earlobe skin structures were printed with stereolithography (SLA), direct light processing (DLP), and PolyJet methods (n=4). DLP and SLA prototype specimens were duplicated in wax. All specimens were then transferred into medical-grade silicone. Rz values of the wrinkle test blocks and the root mean square error (RMSE) of the earlobe test blocks were evaluated by laser topography to determine the trueness and precision of each stage. RESULTS: For the earlobe test blocks, the PolyJet method had superior trueness and precision of the final skin surface reproduction. The SLA method showed the poorest trueness, and the DLP method, the lowest precision. For the wrinkle test blocks, the PolyJet method had the best wrinkle profile reproduction level, followed by DLP and SLA. CONCLUSIONS: The indirect mold-making approach of facial prostheses manufacturing may be associated with 7% of skin surface profile loss with SLA, up to 20% with DLP, and no detail loss with PolyJet.

Shock Absorption Behavior of Elastic Polymers for Sports Mouthguards: An In Vitro Comparison of Thermoplastic Forming and Additive Manufacturing.

BACKGROUND: There are several in vitro testing options to investigate the efficacy of sports mouthguards. None of these represent everyday situations, but the effects of simple laws of physics can be observed. This enables the comparison of conventional materials for mouthguards towards fabrications from additive manufacturing. METHODS: A ball-drop experiment measured the maximum force and temporospatial distribution of a vertical impact on six material groups and a reference group (No-MG). Three conventional materials (ethylenvinylacetate) with 1, 2, and 3 layers were compared with additively manufactured (AM) specimens of comparable layering with a respective thickness of 4 mm, 5 mm, and 6.8 mm. RESULTS: A maximum force of 8982.35 N ± 305.18 (No-MG) was maximum damped to 2470.60 N ± 87.00 (conventional 6.8 mm) compared with 5585.09 N ± 203.99 (AM 6.8 mm) Thereby, the ratio between shock absorption per millimeter was best for 4 mm thickness with means of 1722 N (conventional) and 624 N (AM). CONCLUSIONS: Polymer layers demonstrated a force reduction up to 71.68%. For now, additively processed resins of comparable hardness and layering are inferior to conventional fabrications.

Bonding strength of 3D printed silicone and titanium retention magnets for maxillofacial prosthetics application.

PURPOSE: To assess the bonding between conventional and additively manufactured silicone elastomers and cylindrical retention titanium magnets for anchorage of facial prostheses. METHODS: The customized titanium retention magnets were embedded in conventional and additively produced silicone blocks without primer application (n = 20) and with two commercially available primers G611 (n = 20) and A304 (n = 20) applied onto the magnet surface. The pull out test was performed in the universal testing machine using 45° and 90° angulation and the pull out strength was measured for each group. Additionally the SEM images of the pulled out magnets' surface were obtained and the amount of residual silicone onto the magnet surface was quantified. RESULTS: Significantly higher pull out strength values (p < 0.05) were revealed for 90° specimens (0.11 - 0.17 ± 0.01 N/mm2) compared to the 45° group (0.03 ± 0.02 N/mm2). The pull out test with primer revealed no significant differences between the G 611 and A 304 primers in the additive group. However, significantly (p < 0,05) higher values were observed for conventional specimens in the A304 group (1.10 ± 0.21 N/mm2) compared to the G611 group (0.59 ± 0.27 N/mm2). CONCLUSION: The application of both used primers may be an acceptable technical option for the anchorage of retention titanium magnets in silicone facial prostheses, produced additively in a fully digital workflow.

Accuracy of capturing nasal, orbital, and auricular defects with extra- and intraoral optical scanners and smartphone: An in vitro study.

OBJECTIVES: This in vitro study compares the scanning accuracy of various stationary and portable as well as extra- and intraoral devices for capturing oncological defects. METHODS: A 3D-printed model of a nasal, orbital, and auricular defect, as well as one of an intact auricle, were digitalized (n = 7 per device) with a stationary optical scanner (Pritiface), a portable extraoral optical scanner (Artec Space Spider), two intraoral scanners (Trios 4 and Primescan), and a smartphone (iPhone 11 Pro). For the reference data, the defect models were digitalized using a laboratory scanner (D2000). For quantitative analysis, the root mean square error value for trueness and precision and mean deviations in millimeters were obtained for each defect type. The data were statistically analyzed using two-way ANOVA and Tukey multiple comparison test. For qualitative analysis, a colorimetric map was generated to display the deviation within the defect area and adjacent tissue. RESULTS: Statistically significant interactions were found in the trueness and precision for defect and scanner type. CONCLUSION: The Primescan and Artec Space Spider scanners showed the highest accuracy for most defect types. Primescan and Trios 4 failed to capture the orbital defect. The iPhone 11 Pro showed clinically acceptable trueness but inferior precision. CLINICAL SIGNIFICANCE: The scanning devices may demonstrate varying accuracy, depending on the defect type. A portable extraoral optical scanner is an universal tool for the digitization of oncological defects. Alternatively, an intraoral scanner may be employed in maxillofacial prosthetics with some restrictions. Utilizing a smartphone in maxillofacial rehabilitation should be considered with caution, because it provides inconsistent accuracy.

Implementation of a Full Digital Workflow by 3D Printing Intraoral Splints Used in Dental Education: An Exploratory Observational Study with Respect to Students' Experiences.

Fully digital workflows gained acceptance in dental practice and thereby are of interest for undergraduate education. An exploratory clinical observation was designed to track the implementation of such a workflow with novice digital users in order to describe its feasibility, time investment, and pitfalls. METHODS: Students were invited to provide feedback for their experiences with a training module that consisted of the following: intraoral scanning, computer-aided design (CAD), manual finishing, and insertion of a 3D-printed bite splint for the lower jaw. RESULTS: A total of 82 fourth-year students participated in the module. The average time required to perform an intraoral scan was 17 m 5 s, and all students were able to design a splint with an average time of 2 h 38 m. Students who indicated prior experience with CAD seem to outperform inexperienced students in both CAD task completion and intraoral scanning. The initial fit was reported as clinically acceptable by 68.5% of the participants, while 79% rated the workflow as very good to satisfactory and indicated that the training was helpful for dental practice. CONCLUSIONS: The implementation of a digital workflow in undergraduate dental education is feasible and has acceptable clinical results. However, CAD is time-intensive, and the experience can be challenging.

Multi-Material 3D Printing of a Customized Sports Mouth Guard: Proof-of-Concept Clinical Case.

A multilayer mouth guard is known to have the best protective performance. However, its manufacturing in a digital workflow may be challenging with regards to virtual design and materialization. The present case demonstrates a pathway to fabricate a multilayer individualized mouth guard in a fully digital workflow, which starts with intraoral scanning. A free-form CAD software was used for the virtual design. Two various CAM techniques were used, including Polyjet 3D printing of rubber-like soft material and silicone printing using Drop-on-Demand technique. For both methods the outer layer was manufactured from more rigid materials to facilitate its protective function; the inner layer was printed from a softer material to aid a better adaptation to mucosa and teeth. Both 3D printed multilayer mouth guards showed a clinically acceptable fit and were met with patient appraisal. Their protective capacities must be evaluated in further clinical studies.

3D Printing of Polyamide to Fabricate a Non-Metal Clasp Removable Partial Denture via Fused Filament Fabrication: A Case Report.

The fabrication of a non-metal clasp removable partial denture (RPD) using polymethylmethacrylate in a fully digital workflow has been reported. According to some studies, the polyamide material may be alternatively used for this purpose. The authors are unaware of any reports concerning the additive manufacturing of polyamide. The current proof-of-concept dental technique describes the pathway to construct the non-metal clasp RPD using intraoral scanning and fused filament fabrication (FFF) printing of gingiva-colored polyamide. The present RPD showed acceptable fit and sufficient retention and was considered a valid temporary treatment option.

Bonding Behavior of Conventional PMMA towards Industrial CAD/CAM PMMA and Artificial Resin Teeth for Complete Denture Manufacturing in a Digital Workflow.

When applying a digital workflow, custom artificial resin teeth have to be integrated into a milled complete denture base, using polymethylmethacrylate (PMMA) applied with a powder-liquid technique. Debonding of denture teeth from dentures is reported to be a frequent complication. No evidence is provided as to which method of surface treatment may enhance the bonding strength. The bonding strength between artificial teeth and PMMA (Group A, n = 60), as well as between the PMMA and industrial PMMA (Group B, n = 60), was investigated following no treatment, monomer application, sandblasting, oxygen plasma, and nitrogen plasma treatment. Surface-roughness values and SEM images were obtained for each group. Shear bond strength (SBS) and fracture mode were analyzed after thermocycling. Within Group A, statistically significant higher SBS was found for all surface treatments, except for nitrogen plasma. In Group B, only nitrogen plasma showed a statistically lower SBS compared to the reference group which was equivalent to all surface treatments. Conclusions: Within the limitations of the present study, the monomer application can be proposed as the most effective surface-treatment method to bond custom artificial teeth into a milled PMMA denture base, whereas nitrogen plasma impairs the bonding strength.

Bonding Interface and Repairability of 3D-Printed Intraoral Splints: Shear Bond Strength to Current Polymers, with and without Ageing.

This in-vitro study investigates the bonding interfaces reached by the conditioning of a splint material additively manufactured by digital light processing (AM base) as well as the shear bond strength (SBS) of resins bonded to these surfaces (repair material). Therefore, the AM base was either stored in dry for 12 h or wet environment for 14 days to simulate ageing by intraoral wear. The dry and wet group was bonded after physical and/or chemical conditioning to cylinders made from polymethylmethacrylate or four novel polymers allowing splint modifications. Blasted and methylmethacrylate (MMA)-conditioned Polymethylmethacrylate (PMMA) bonded to PMMA acted as the gold standard. The surface profiles revealed highest differences of Ra towards the gold standard in AM base conditioned with other than MMA after sandblasting. The adhesively bonded repair materials of the wet AM base were further aged in wet environment for 14 days. The SBS of the gold standard (25.2 MPa and 25.6 MPa) was only reached by PMMA bonded to blasted and MMA-conditioned AM base after dry (22.7 MPa) and non-conditioned after wet storage (23 MPa). Four repair materials failed to reach the threshold of 5 MPa after dry storage and three after wet storage, respectively. Non-conditioned AM base revealed the highest risk for adhesive fractures when using other resins than PMMA.

Flowability, Tear Strength, and Hydrophilicity of Current Elastomers for Dental Impressions.

This study investigates 2 polyethers (PE), 2 polyvinylsiloxanethers (VXSE), and 10 polyvinylsiloxanes (PVS), seven of which had a corresponding light-body consistency and seven of which had a corresponding heavy-body consistency. Each light-body elastomer underwent a flowability test using the shark fin method 20, 50, and 80 s after mixing. The tear strength test DIN 53504 was used after setting the time (T0). Next, 24 h later (T1), hydrophilicity testing was used with static contact angles in water drops during polymerization (20, 50, and 80 s, as well as after 10 min). The heavy-body elastomers underwent shark fin testing with a corresponding light-body material at 50 and 80 s after mixing. The results of light-body testing were combined in a score to describe their performance. The highest differences were detected within flowability in shark fin heights between PE and a PVS (means of 15.89 and 6.85 mm) within the maximum tear strengths at T0 between a PVS and PE (3.72 and 0.75 MPa), as well as within hydrophilicity during setting between VXSE and a PVS (15.09° and 75.5°). The results indicate that VSXE and novel PVS materials can significantly compensate shortcomings in PE towards tear strength and hydrophilicity, but not flowability.

[Dental and oral health services research in Germany]. / Versorgungsforschung in der Zahnmedizin in Deutschland.

Over the past eight years, the continuous call for "more oral health services research" in Germany has been (at least partially) answered. Today, relevant oral and dental health services research activities can be found at 12 medical faculties in Germany and nine large-scale projects are funded by the German Ministry for Education and Research (BMBF) or the Innovation Fund of the Federal Joint Committee (G-BA). However, the demand for high-level research in this field exceeds the current capacities of university and non-university dentistry; structured and methodically competent research networks that are cross-linked within the dental and public health services are required. These would allow research to assure sustainable and demand-oriented dental services, scientifically supporting the demographically, economically, and socially driven major changes to be expected in the coming years.The article describes the current status of dental and oral health services research in Germany and addresses major challenges: methodological competence, data accessibility and usage, and the prospects for this field of research. Therefore, it takes stock of existing research activities and infrastructure (including educational and funding opportunities).Knowledge obtained from dental and oral health services research in Germany can be pioneering for other countries, while researchers in Germany may be able to adopt and adapt servicing strategies from other countries and health systems for Germany. To achieve these aims, dental and oral health services researchers should professionalize and network. Sustainable structures (professorships, staff) and frameworks (data availability, funding) should be established and findings promptly translated into use.

How to support dental students in reading radiographs: effects of a gaze-based compare-and-contrast intervention.

In dental medicine, interpreting radiographs (i.e., orthopantomograms, OPTs) is an error-prone process, even in experts. Effective intervention methods are therefore needed to support students in improving their image reading skills for OPTs. To this end, we developed a compare-and-contrast intervention, which aimed at supporting students in achieving full coverage when visually inspecting OPTs and, consequently, obtaining a better diagnostic performance. The comparison entailed a static eye movement visualization (heat map) on an OPT showing full gaze coverage from a peer-model (other student) and another heat map showing a student's own gaze behavior. The intervention group (N = 38) compared five such heat map combinations, whereas the control group (N = 23) diagnosed five OPTs. Prior to the experimental variation (pre-test) and after it (post-test), students in both conditions searched for anomalies in OPTs while their gaze was recorded. Results showed that students in the intervention group covered more areas of the OPTs and looked less often and for a shorter amount of time at anomalies after the intervention. Furthermore, they fixated on low-prevalence anomalies earlier and high-prevalence anomalies later during the inspection. However, the students in the intervention group did not show any meaningful improvement in detection rate and made more false positive errors compared to the control group. Thus, the intervention guided visual attention but did not improve diagnostic performance substantially. Exploratory analyses indicated that further interventions should teach knowledge about anomalies rather than focusing on full coverage of radiographs.

Multimaterial 3D printing of a definitive silicone auricular prosthesis: An improved technique.

Direct silicone printing has been reported for the manufacture of interim facial prostheses. The recent advancements in printing hardware have allowed for multimaterial simultaneous silicone printing with 4 nozzles. With this technology, an auricular prosthesis was printed with various grades of Shore hardness. A few analog steps, including polishing, sealing, coloring, and relining, resulted in an individualized prosthesis with a thin frontal margin and smooth transition into the adjacent tissue. It was considered a definitive treatment option.

How massed practice improves visual expertise in reading panoramic radiographs in dental students: An eye tracking study.

The interpretation of medical images is an error-prone process that may yield severe consequences for patients. In dental medicine panoramic radiography (OPT) is a frequently used diagnostic procedure. OPTs typically contain multiple, diverse anomalies within one image making the diagnostic process very demanding, rendering students' development of visual expertise a complex task. Radiograph interpretation is typically taught through massed practice; however, it is not known how effective this approach is nor how it changes students' visual inspection of radiographs. Therefore, this study investigated how massed practice-an instructional method that entails massed learning of one type of material-affects processing of OPTs and the development of diagnostic performance. From 2017 to 2018, 47 dental students in their first clinical semester diagnosed 10 OPTs before and after their regular massed practice training, which is embedded in their curriculum. The OPTs contained between 3 to 26 to-be-identified anomalies. During massed practice they diagnosed 100 dental radiographs without receiving corrective feedback. The authors recorded students' eye movements and assessed the number of correctly identified and falsely marked low- and high prevalence anomalies before and after massed practice. Massed practice had a positive effect on detecting anomalies especially with low prevalence (p < .001). After massed practice students covered a larger proportion of the OPTs (p < .001), which was positively related to the detection of low-prevalence anomalies (p = .04). Students also focused longer, more frequently, and earlier on low-prevalence anomalies after massed practice (ps < .001). While massed practice improved visual expertise in dental students with limited prior knowledge, there is still substantial room for improvement. The results suggest integrating massed practice with more deliberate practice, where, for example, corrective feedback is provided, and support is adapted to students' needs.

Retention Forces of Prosthetic Clasps over a Simulated Wearing Period of Six Years In-Vitro: Direct Metal Laser Melting Versus Dental Casting.

This study determinates the persistence of retention force in Akers-clasps for removable partial dentures made from Co-Cr alloy. Therefore, standardized computer-aided designed (CAD) clasp #1 specimens were made by direct metal laser melting (DMLM, n = 10) and by lost-wax dental casting (DC) of computer-aided manufactured (CAM) replicas (n = 10, DC) from two comparable Co-Cr alloys. The retention force was tested after manufacturing for 9000 cycles of setting and removal from a molar tooth crown analog made from zirconia; simulating in-vitro a duration of six years in service. The first and last 360 cycles (T0 and T1, 3 months each) of all specimens were selected for comparison of retention forces between the materials. A constant decrease of 6% from the initial retention force (T0 = 4.86 N, SD = 0.077; T1 = 4.57 N, SD = 0.037) was detected at the DC specimens, and an increase of 4% in DMLM specimens (T0 = 5.69 N, SD = 0.078; T1 = 5.92 N, SD = 0.077); all differences were statistically significant (p < 0.0001). Even if these deviations are not of clinical relevance, further studies and applications should investigate the fatigue behavior of laser melted Co-Cr-alloys for dental application.

Rehabilitation of a maxillary partial edentulous patient using an implant-supported overdenture retained with two bilateral milled bars.

The use of implants has enabled more treatment options for prosthetic rehabilitation of partially and completely edentulous patients. This clinical report describes a treatment approach for an 80-year-old patient taking advantage of the remaining natural teeth for prosthetic rehabilitation. The final treatment plan included natural tooth-supported and implant-supported crowns combined with a milled bar partial overdenture retained by tilted dental implants. The overdentures supported by the milled bar implants provide the advantages of both fixed and removable restorations. In addition to patient satisfaction, the overdentures also minimise alveolar bone resorption, increase longevity and stability and improve masticatory efficiency.

Influence of minimal extended firing on dimensional, optical, and mechanical properties of crystalized zirconia-reinforced lithium silicate glass ceramic.

This study should evaluate the influence of extended firing on the dimension, optical properties and flexural strength of a fully crystalized zirconia-reinforced lithium-silicate ceramic (ZLS) for single tooth restorations. METHODS: 150 ZLS (Celtra Duo) and 30 lithium disilicate (LDS, IPS e.max CAD) specimens (17 × 4 × 1 mm) were milled in a standard device (Cerec MC XL). The ZLS specimens were distributed equally to five experimental groups (polished, standard firing [IFU], and three extended firings). LDS acted as a control group. The extended firings of ZLS addressed the first glaze firing (EF1) as well as the subsequent glaze firing (EF2) by a controlled overheating of +15 °C during the holding time. Color was measured with a digital spectrophotometer (Shadepilot), and dimensions with a digital calliper, before and after firing. A color change of ΔE ≥1.5 and a volume change of ±0.5% was regarded as clinical relevant. All specimens underwent a three-point-bending test to calculate flexural strength and Weibull statistics. RESULTS: The color change after firing of ZLS (ΔE value; mean = 1.06; SD = 0.53) exceeded the perceptible threshold of ΔE ≥1.5 in 20% of IFU (mean = 1.18) and EF1+2 (mean = 0.95), 23% of EF1 (mean = 1.11), and 10% of EF2 (mean = 0.99) specimens with no statistical difference between the experimental groups. In 80% of IFU, 63% of EF2, 56% of EF1, and 33% of EF1+2 vol. change after firing exceeded ±0.5%. Characteristic Weibull strength σ0 and modulus m of polished ZLS specimen was affected by firing in IFU (σ0 = 314.35 MPa; m = 5.81), EF1 (σ0 = 324.68 MPa; m = 5.67), EF2 (σ0 = 326.4 MPa; m = 7.24), and EF1+2 (σ0 = 357.15 MPa, m = 3.69). LDS revealed σ0 = 405.7 MPa; m = 8.04, and polished ZLS σ0 = 219.3 MPa; m = 8.9 with statistical significant difference of the flexural strength between all fired ZLS experimental groups towards "as polished" as well as LDS. CONCLUSION: Firing of ZLS led to changes in dimensions, color, and Weibull modulus. Firing increases flexural strength, but minimal temperature extension also increases materials inhomogeneity and risk of failure. The findings call for further investigations towards firing behavior of ZLS and its clinical relevance for restorations.