Intraoral low-temperature degradation of monolithic zirconia dental prostheses: 5-year results of a prospective clinical study with ex vivo monitoring.

OBJECTIVES: To investigate the 5-year intraoral evolution and kinetics of low-temperature degradation (LTD) of second-generation monolithic prostheses made of 3% molar yttrium-doped tetragonal zirconia polycrystal (3Y-TZP) and the influence of masticatory mechanical stresses and glaze layer on this evolution. METHODS: A total of 101 posterior tooth elements were included in this prospective clinical study, which comprised ex vivo LTD monitoring (at baseline, 6 months, 1 year, 2 years, 3 years, and 5 years) using Raman spectroscopy (n = 2640 monoclinic phase measurement points per evaluation time) and scanning electron microscopy (SEM). Four types of areas (1-2 mm2 surface, six on molars, and four on premolars) were analysed on each element surface: occlusal, axial, glazed, or unglazed. Raman mapping, high-resolution SEM, and focused ion beam-SEM were performed on selected samples. RESULTS: The dental prostheses developed a tetragonal-to-monoclinic transformation at the extreme surface of the material after six months in a buccal environment, and this process increased significantly over time. Over the five years of monitoring, the transformation developed nonuniformly with the presence of localised clusters of monoclinic grains. Tribological stresses generate grain pull-out from these clusters, which may raise questions regarding the release of 3Y-TZP nanoparticles into the body. The prosthesis fracture rate was 4.5% after 5 years. SIGNIFICANCE: LTD developed in vivo on the surfaces of 3Y-TZP dental prostheses and progressed slowly but significantly over time, up to 5 years investigation. However, the effects of aging on the failure rate recorded and of zirconia nanoparticles released into the body require further investigation.

Intraoral low-temperature degradation of monolithic zirconia dental prostheses: Results of a prospective clinical study with ex vivo monitoring.

OBJECTIVE: To investigate the intraoral development and kinetics of low-temperature degradation (LTD) in second-generation 3 mol.% yttria-doped tetragonal zirconia polycrystal (3Y-TZP) monolithic prostheses, as well as the influence of masticatory mechanical stress and glaze layer on it. METHODS: A total of 101 posterior tooth elements were included in a prospective clinical study, which included ex vivo LTD monitoring (at baseline, 6 months, 1 year, and 2 years) using Raman spectroscopy (n = 2640 monoclinic phase measurement points per evaluation time) and SEM. Four types of areas (1-2 mm2 surface, 6 on molars, and 4 on premolars) were analyzed on each element surface: occlusal, axial, glazed, or unglazed. Raman depth mapping and high-resolution SEM were performed on the selected samples. RESULTS: LTD developed in 3Y-TZP monolithic restorations 6 months after intraoral placement and progressed with time. After two years, the tetragonal-to-monoclinic transformation was non-uniform, with the presence of localized clusters of transformed grains. In axial areas, the grain aspect was typical of the classical nucleation-growth process reported for LTD, which progresses from the surface to a depth of several tens of microns. However, in occlusal areas, tribological stress generated surface crushing and grain pull-out from the clusters, which induced an underestimation of the aging process when the evaluation was limited to monoclinic phase quantification. Glazing cannot be considered a protection against LTD. SIGNIFICANCE: If LTD occurs in dental prostheses in the same way as in orthopedic prostheses, its clinical impact is unknown and needs to be further studied.

The one-step no-prep approach for full-mouth rehabilitation of worn dentition using PICN CAD-CAM restorations: 2-yr results of a prospective clinical study.

OBJECTIVES: To prospectively evaluate the One-step No-prep treatment of full mouth-worn dentition, a minimally invasive and multidisciplinary approach using PICN CAD-CAM composite restorations without provisional phase. METHODS: Seven patients (n = 192 restorations) with severe tooth wear were included. Patient data were recorded, and an occlusal analysis and a tissue-guided wax-up were realized. After replacement of old fillings, no-prep Vita Enamic restorations (posterior restorations and palatal veneers) were bonded within 24 h. Direct composites were performed to mask the buccal joint on anterior teeth. Maxillo-facial physiotherapy was performed. Restorations were evaluated following World Dental Federation criteria. Treatment influence on Oral-Health-Impact-Profile-49 (OHIP-49) score was assessed. RESULTS: Tooth wear etiology was related to soft drink consumption and bruxism. Mean VDO increase was 5.09 ±â€¯0.85 mm on the incisal pin. The mean restoration thickness on molars was 0.55 ±â€¯0.21 mm, and the lowest was 0.11 mm. 2-year survival rate of restorations was 100 % and success rate was 93.5 %, with 11 minor chippings and one debonding. A significant improvement of the global OHIP-49 score was observed. CONCLUSIONS: In this clinical study on high risk patients, PICN restorations, applied in a minimally invasive way, showed high survival and success rates after two years, while minor chipping of very thin occlusal borders constituted the most frequent complication. Moreover, the patient acceptance was good according to OHIP-49 in this multidisciplinary approach. CLINICAL SIGNIFICANCE: The use of PICNs allows the development of no prep and simple treatment protocols of worn dentition. The absence of provisionals did not engender any problem, on the basis of the realization of an occlusal analysis, the support of a maxillo-facial physiotherapist, and the use of an easy-to-adjust restorative material.

Clinical behavior of second-generation zirconia monolithic posterior restorations: Two-year results of a prospective study with Ex vivo analyses including patients with clinical signs of bruxism.

OBJECTIVES: This study aimed to investigate (1) clinical outcomes of second-generation zirconia restorations, including patients with bruxism clinical signs, and (2) the material wear process. METHODS: A total of 95 posterior monolithic zirconia tooth-elements in 45 patients were evaluated, 85 on implants and 10 on natural teeth, and 20.3% of restorations being fixed partial dentures (FPDs). Occlusal contact point areas were determined and half of those areas were left unglazed and just polished. Restorations were clinically evaluated following criteria of the World Dental Federation and antagonistic teeth were examined at each evaluation time. Wear ex vivo analyses using SEM and 3D laser profilometry were performed at baseline and after 6 months, 1 year, and 2 years respectively, temporarily removing the prostheses. RESULTS: The Kaplan-Meier survival rate of restorations was 93.3% (100% for FPDs) and the success rate was 81.8%, with 4 abutment debondings, 3 tooth-supported crown debondings (provisional cement use), 1 restoration fracture, 1 minor chipping, 1 core fracture, 1 root fracture, and 2 implant losses. 80% of catastrophic failures occurred in patients with clinical signs of bruxism (61.7% of patients). Complications were also observed on antagonistic teeth (3 catastrophic failures). Clinical evaluation of the restorations showed good results from the aesthetic, functional, and biological perspective. Zirconia wear was inferior to 15 µm, while glaze wear was observed on all occlusal contact areas after 1 year. CONCLUSIONS: Monolithic zirconia FPDs are promising but the failure rate of single-unit restorations was not as high as expected in this sample including patients with bruxism clinical signs. CLINICAL SIGNIFICANCE: Within study limitations, FPDs showed excellent short-term results but further research is needed for single-unit restorations considering samples, which do not exclude bruxers. The weak link is the restoration support or the antagonist tooth, one hypothesis being that zirconia stiffness and lack of resilience do not promote occlusal stress damping.

A Functionally Graded PICN Material for Biomimetic CAD-CAM Blocks.

The objective of this study was to introduce a functionally graded (FG) polymer-infiltrated ceramic network (PICN) block, characterized by a gradient of mechanical properties, as a biomimetic material for computer-aided design and manufacturing (CAD-CAM) prostheses. FG-PICN blocks were manufactured from a slurry of glass-ceramic powder, which was subsequently centrifuged and sintered. The ceramic network was infiltrated with urethane dimethacrylate and polymerized under high temperature-pressure. Blocks were sectioned into 9 layers, and each layer was subsequently cut into 3 samples. Samples were loaded into a 3-point bending device and tested for flexural strength, flexural load energy, and flexural modulus. The volume percentage of glass-ceramic, hardness, and brittleness index were also measured and scanning electron microscopy (SEM) observations were performed. Katana translucent zirconia (HT-ZIR) and e.max-CAD (EMX) were tested for comparison. Flexural strength, flexural load energy, and Weibull modulus of FG-PICN were shown to increase from the first (enamel-like zone) to the ninth layer (dentin-like zone), while, on the contrary, flexural modulus, hardness, brittleness index, and ceramic volume percentage decreased. SEM characterization highlighted a higher porosity in layer 9 than in layer 1. Flexural strength of the dentin-like zone (372.7 ± 27.8 MPa) was similar to EMX and lower than HT-ZIR. Flexural modulus was shown to vary from 41.9 ± 5.1 to 28.6 ± 2.0 GPa from surface to depth. Flexural load energy in the dentin-like zone (27.1 ± 4.9 mJ) was significantly superior to EMX and HT-ZIR. Hardness gradient was shown to be close to tooth tissues. This work introduces FG-PICN blocks, with a gradient of mechanical and optical properties through the entire thickness of the block designed to mimic dental tissues. FG-PICN demonstrated a favorable gradient of flexural strength, elastic modulus, and, most of all, flexural load energy and hardness compared to other CAD-CAM materials, which can promote the biomechanical behavior of single-unit restorations on teeth and implants.

Wear measurement of dental tissues and materials in clinical studies: A systematic review.

OBJECTIVES: This study aims to systematically review the different methods used for wear measurement of dental tissues and materials in clinical studies, their relevance and reliability in terms of accuracy and precision, and the performance of the different steps of the workflow taken independently. METHODS: An exhaustive search of clinical studies related to wear of dental tissues and materials reporting a quantitative measurement method was conducted. MedLine, Embase, Scopus, Cochrane Library and Web of Science databases were used. Prospective studies, pilot studies and case series (>10 patients), as long as they contained a description of wear measurement methodology. Only studies published after 1995 were considered. RESULTS: After duplicates' removal, 495 studies were identified, and 41 remained for quantitative analysis. Thirty-four described wear-measurement protocols, using digital profilometry and superimposition, whereas 7 used alternative protocols. A specific form was designed to analyze the risk of bias. The methods were described in terms of material analyzed; study design; device used for surface acquisition; matching software details and settings; type of analysis (vertical height-loss measurement vs volume loss measurement); type of area investigated (entire occlusal area or selective areas); and results. SINIFICANCE: There is a need of standardization of clinical wear measurement. Current methods exhibit accuracy, which is not sufficient to monitor wear of restorative materials and tooth tissues. Their performance could be improved, notably limiting the use of replicas, using standardized calibration procedures and positive controls, optimizing the settings of scanners and matching softwares, and taking into account unusable data.

Bonding to CAD-CAM Composites: An Interfacial Fracture Toughness Approach.

The objective of this study was to evaluate the interfacial fracture toughness (IFT) of composite cement with dispersed filler (DF) versus polymer-infiltrated ceramic network (PICN) computer-aided design and computer-aided manufacturing (CAD-CAM) composite blocks after 2 different surface pretreatments using the notchless triangular prism (NTP) test. Two DFs (Cerasmart [CRT] and Lava Ultimate [LVA]), 2 PICNs (Enamic [ENA] and experimental PICN [EXP]), and e.max CAD lithium disilicate glass-ceramic (EMX, control) prism samples were bonded to their counterparts with Variolink Esthetic DC composite cement after either hydrofluoric acid etching (HF) or gritblasting (GR). Both procedures were followed by silanization. All samples ( n = 30 per group) were thermocycled (10,000 cycles) and tested for their IFT in a water bath at 36°C. Moreover, representative samples from each group were subjected to a developed interfacial area ratio (Sdr) measurement by profilometry and scanning electron microscopy (SEM) characterization. EXP-HF gave the highest IFT (1.85 ± 0.39 MPa·m1/2), followed by EMX-HF and ENA-HF, while CRT-HF gave the lowest (0.15 ± 0.22 MPa·m1/2). PICNs gave significantly better results with HF, and DF showed better results with GR. A 2-way analysis of variance indicated that there were significantly higher IFT and Sdr for PICNs than for DF. A positive correlation ( r² = 0.872) was found between IFT and Sdr. SEM characterization showed the specific microstructure of the surface of etched PICNs, indicating the presence of a retentive polymer-based honeycomb structure. Etching of the typical double-network microstructure of PICNs causes an important increase in the Sdr and IFT, while DF should be gritblasted. DF exhibited significantly lower Sdr and IFT values than PICNs. The present results show the important influence of the material class and surface texture, and consequently the micromechanical bond, on the adhesive interface performance of CAD-CAM composites.

From Artisanal to CAD-CAM Blocks: State of the Art of Indirect Composites.

Indirect composites have been undergoing an impressive evolution over the last few years. Specifically, recent developments in computer-aided design-computer-aided manufacturing (CAD-CAM) blocks have been associated with new polymerization modes, innovative microstructures, and different compositions. All these recent breakthroughs have introduced important gaps among the properties of the different materials. This critical state-of-the-art review analyzes the strengths and weaknesses of the different varieties of CAD-CAM composite materials, especially as compared with direct and artisanal indirect composites. Indeed, new polymerization modes used for CAD-CAM blocks-especially high temperature (HT) and, most of all, high temperature-high pressure (HT-HP)-are shown to significantly increase the degree of conversion in comparison with light-cured composites. Industrial processes also allow for the augmentation of the filler content and for the realization of more homogeneous structures with fewer flaws. In addition, due to their increased degree of conversion and their different monomer composition, some CAD-CAM blocks are more advantageous in terms of toxicity and monomer release. Finally, materials with a polymer-infiltrated ceramic network (PICN) microstructure exhibit higher flexural strength and a more favorable elasticity modulus than materials with a dispersed filler microstructure. Consequently, some high-performance composite CAD-CAM blocks-particularly experimental PICNs-can now rival glass-ceramics, such as lithium-disilicate glass-ceramics, for use as bonded partial restorations and crowns on natural teeth and implants. Being able to be manufactured in very low thicknesses, they offer the possibility of developing innovative minimally invasive treatment strategies, such as "no prep" treatment of worn dentition. Current issues are related to the study of bonding and wear properties of the different varieties of CAD-CAM composites. There is also a crucial need to conduct clinical studies. Last, manufacturers should provide more complete information regarding their product polymerization process, microstructure, and composition, which significantly influence CAD-CAM material properties.

Residual stress profiles in veneering ceramic on Y-TZP, alumina and ZTA frameworks: measurement by hole-drilling.

OBJECTIVES: The residual stress profile developed within the veneering ceramic during the manufacturing process is an important predicting factor in chipping failures, which constitute a well-known problem with yttria-tetragonal-zirconia polycrystal (Y-TZP) based restorations. The objectives of this study are to measure and to compare the residual stress profile in the veneering ceramic layered on three different polycrystalline ceramic framework materials: Y-TZP, alumina polycrystal (AL) and zirconia toughened alumina (ZTA). METHODS: The stress profile was measured with the hole-drilling method in bilayered disk samples of 19 mm diameter with a 0.7 mm thick Y-TZP, AL or ZTA framework and a 1.5mm thick layer of the corresponding veneering ceramic. RESULTS: The AL samples exhibited increasing compressive stresses with depth, while compressive stresses switching into interior tensile stresses were measured in Y-TZP samples. ZTA samples exhibited compressive stress at the ceramic surface, decreasing with depth up to 0.6mm from the surface, and then becoming compressive again near the framework. SIGNIFICANCE: Y-TZP samples exhibited a less favorable stress profile than those of AL and ZTA samples. Results support the hypothesis of the occurrence of structural changes within the Y-TZP surface in contact with the veneering ceramic to explain the presence of tensile stresses. Even if the presence of Y-TZP in the alumina matrix seems to negatively affect the residual stress profiles in ZTA samples in comparison with AL samples, the registered profiles remain positive in terms of veneer fracture resistance.

[Failure of zirconia-based prostheses on natural teeth and implants: focus on risk factors]. / Echecs des prothèses dentaires et implantaires en zircone : le point sur les facteurs de risqué.

Cohesive fracture of the veneering ceramic (chipping) is the first cause of failure of zirconia-based prostheses on natural teeth and implants. Besides risk factors related to the material (thermal stresses generated during the manufacturing process, framework inappropriate design), there are some clinical risk factors, which can influence the restoration prognosis. Indeed, unfavorable occlusal relationships and/or the presence of parafunctions such as bruxism and clenching, which are frequent pathologies, engender significant overloading. A retrospective study was performed at the University Hospital Center (CHU) of Liege on 147 dental and implants prostheses, placed between May 2003 and January 2012. This study highlighted a significant correlation between chipping and the absence of an occlusal nightguard (p = 0.0048), the presence of a ceramic restoration as an antagonist (p = 0.013), the presence of occlusal parafunctions (p = 0.018), and the presence of implants as support of the restorations (p = 0.026). These results underline the importance of external stress and occlusal risk factors diagnosis, as the need to perform an occlusal nightguard to patients with parafunctions.

Antibiotic prescribing in dental practice in Belgium.

AIM: To assess the types and frequency of antibiotic prescriptions by Belgian dentists, the indications for antibiotic prescription, and dentists' knowledge about recommended practice in antibiotic use. METHODOLOGY: In this cross-sectional survey, dental practitioners were asked to record information about all antibiotics prescribed to their patients during a 2-week period. The dental practitioners were also asked to complete a self-administered questionnaire regarding demographic data, prescribing practices, and knowledge about antibiotic use. A random sample of 268 Belgian dentists participated in the survey. RESULTS: During the 2-week period, 24 421 patient encounters were recorded; 1033 patients were prescribed an antibiotic (4.2%). The median number of prescriptions per dentist for the 2 weeks was 3. Broad spectrum antibiotics were most commonly prescribed: 82% of all prescriptions were for amoxycillin, amoxycillin-clavulanic acid and clindamycin. Antibiotics were often prescribed in the absence of fever (92.2%) and without any local treatment (54.2%). The most frequent diagnosis for which antibiotics were prescribed was periapical abscess (51.9%). Antibiotics were prescribed to 63.3% of patients with periapical abscess and 4.3% of patients with pulpitis. Patterns of prescriptions were confirmed by the data from the self-reported practice. CONCLUSIONS: Discrepancies between observed and recommended practice support the need for educational initiatives to promote rational use of antibiotics in dentistry in Belgium.

[The global impression technic in fixed dentures]. / Les empreintes globales en prothèse fixée.

The global impression technique allows to obtain in a single stage the impression of the abutment as well as their neighboring teeth. This technique often requires the placement of one or two retraction cords in the sulcus. The impression technique herein described is the double mix method. This method is based on the use of two elastomers with different viscosities, but from the same group thus allowing a simultaneous polymerization.