Predicting the Debonding of CAD/CAM Composite Resin Crowns with AI.

A preventive measure for debonding has not been established and is highly desirable to improve the survival rate of computer-aided design/computer-aided manufacturing (CAD/CAM) composite resin (CR) crowns. The aim of this study was to assess the usefulness of deep learning with a convolution neural network (CNN) method to predict the debonding probability of CAD/CAM CR crowns from 2-dimensional images captured from 3-dimensional (3D) stereolithography models of a die scanned by a 3D oral scanner. All cases of CAD/CAM CR crowns were manufactured from April 2014 to November 2015 at the Division of Prosthodontics, Osaka University Dental Hospital (Ethical Review Board at Osaka University, approval H27-E11). The data set consisted of a total of 24 cases: 12 trouble-free and 12 debonding as known labels. A total of 8,640 images were randomly divided into 6,480 training and validation images and 2,160 test images. Deep learning with a CNN method was conducted to develop a learning model to predict the debonding probability. The prediction accuracy, precision, recall, F-measure, receiver operating characteristic, and area under the curve of the learning model were assessed for the test images. Also, the mean calculation time was measured during the prediction for the test images. The prediction accuracy, precision, recall, and F-measure values of deep learning with a CNN method for the prediction of the debonding probability were 98.5%, 97.0%, 100%, and 0.985, respectively. The mean calculation time was 2 ms/step for 2,160 test images. The area under the curve was 0.998. Artificial intelligence (AI) technology-that is, the deep learning with a CNN method established in this study-demonstrated considerably good performance in terms of predicting the debonding probability of a CAD/CAM CR crown with 3D stereolithography models of a die scanned from patients.

Fifteen-year survival of resin-bonded vs full-coverage fixed dental prostheses.

PURPOSE: We clarified cumulative survival and event-free rates of resin-bonded fixed dental prostheses (RBFDPs) and compared them to those of fixed dental prostheses (FDPs) to refine risk factors for non-survival/event and use of tooth extraction after the period of non-survival/event. METHODS: Study subjects were selected among all patients who consecutively attended the Fixed Prosthodontic Clinic of Okayama University Hospital. Eligible patients were those who received 3-unit metal-framed 2-retainer (wing-wing) RBFDPs or conventional full-coverage FDPs (RBFDPs/FDPs: 129/177 prostheses). Data were analyzed by Kaplan-Meier analysis with the log-rank test, Mann-Whitney test, chi-square test, and Cox proportional hazards analysis. RESULTS: The 15-year cumulative survival rates were 66.5% for the RBFDP group and 61.6% for the FDP group, which were not significantly different (p = 0.59). The 15-year cumulative event-free rates were 53.4% for the RBFDP group and 59.2% for the FDP group, which were not significantly different (p = 0.52). No significant risk factors related to non-survival and event-free of RBFDPs/FDPs were identified in the analysis model using treatment method, sex, age, number of remaining teeth, and treatment site as explanatory variables. The number of cases in which RBFDPs/FDPs resulted in non-survival due to abutment tooth extraction was significantly lower in RBFDPs (p < 0.01). Further, the abutment tooth as a non-vital tooth was identified as a risk factor for RBFDPs/FDPs resulting in non-survival due to abutment tooth extraction. CONCLUSIONS: The present study is the first to indicate RBFDP as a prosthetic treatment option which should be selected for patients with slight or no abutment tooth decay.

Advanced Statistical Analyses to Reduce Inconsistency of Bond Strength Data.

This study was designed to clarify the interrelationship of factors that affect the value of microtensile bond strength (µTBS), focusing on nondestructive testing by which information of the specimens can be stored and quantified. µTBS test specimens were prepared from 10 noncarious human molars. Six factors of µTBS test specimens were evaluated: presence of voids at the interface, X-ray absorption coefficient of resin, X-ray absorption coefficient of dentin, length of dentin part, size of adhesion area, and individual differences of teeth. All specimens were observed nondestructively by optical coherence tomography and micro-computed tomography before µTBS testing. After µTBS testing, the effect of these factors on µTBS data was analyzed by the general linear model, linear mixed effects regression model, and nonlinear regression model with 95% confidence intervals. By the general linear model, a significant difference in individual differences of teeth was observed ( P < 0.001). A significantly positive correlation was shown between µTBS and length of dentin part ( P < 0.001); however, there was no significant nonlinearity ( P = 0.157). Moreover, a significantly negative correlation was observed between µTBS and size of adhesion area ( P = 0.001), with significant nonlinearity ( P = 0.014). No correlation was observed between µTBS and X-ray absorption coefficient of resin ( P = 0.147), and there was no significant nonlinearity ( P = 0.089). Additionally, a significantly positive correlation was observed between µTBS and X-ray absorption coefficient of dentin ( P = 0.022), with significant nonlinearity ( P = 0.036). A significant difference was also observed between the presence and absence of voids by linear mixed effects regression analysis. Our results showed correlations between various parameters of tooth specimens and µTBS data. To evaluate the performance of the adhesive more precisely, the effect of tooth variability and a method to reduce variation in bond strength values should also be considered.

Development of a Cavity Disinfectant Containing Antibacterial Monomer MDPB.

An experimental cavity disinfectant (ACC) that is intended to be used for various direct and indirect restorations was prepared by adding an antibacterial monomer 12-methacryloyloxydodecylpyridinum bromide (MDPB) at 5% into 80% ethanol. The antibacterial effectiveness of ACC and its influences on the bonding abilities of resin cements were investigated. To examine the antibacterial activity of unpolymerized MDPB, the minimum inhibitory and bactericidal concentrations (MIC and MBC) were determined for Streptococcus mutans, Lactobacillus casei, Actinomyces naeslundii, Parvimonas micra, Enterococcus faecalis, Fusobacterium nucleatum, and Porphyromonas gingivalis Antibacterial activities of ACC and the commercial cavity disinfectant containing 2% chlorhexidine and ethanol (CPS) were evaluated by agar disk diffusion tests through 7 bacterial species and by MIC and MBC measurement for S. mutans The effects of ACC and CPS to kill bacteria in dentinal tubules were compared with an S. mutans-infected dentin model. Shear bond strength tests were used to examine the influences of ACC on the dentin-bonding abilities of a self-adhesive resin cement and a dual-cure resin cement used with a primer. Unpolymerized MDPB showed strong antibacterial activity against 7 oral bacteria. ACC produced inhibition zones against all bacterial species similar to CPS. For ACC and CPS, the MIC value for S. mutans was identical, and the MBC was similar with only a 1-step dilution difference (1:2). Treatment of infected dentin with ACC resulted in significantly greater bactericidal effects than CPS (P < 0.05, analysis of variance and Tukey's honest significant difference test). ACC showed no negative influences on the bonding abilities to dentin for both resin cements, while CPS reduced the bond strength of the self-adhesive resin cement (P < 0.05). This study clarified that the experimental cavity disinfectant containing 5% MDPB is more effective in vitro than the commercially available chlorhexidine solution to eradicate bacteria in dentin, without causing any adverse influences on the bonding abilities of resinous luting cements.

Clinical effectiveness of contemporary adhesives for the restoration of non-carious cervical lesions. A systematic review.

OBJECTIVES: The aim of this systematic review was to evaluate the clinical effectiveness of contemporary adhesives for the restoration of non-carious cervical lesions (NCCLs) in terms of restoration retention as a function of time. METHODS: Medline Ovid and IADR abstracts were reviewed for NCCLs clinical trials from 1950 to 2013. The reference list of all eligible trials and relevant review articles was checked to find additional studies. The review did not have any language restrictions. Only randomized controlled clinical trials that evaluated at least two adhesives for a follow-up period of at least 18 months were included. Materials with adhesive potential were categorized into 6 main classes: 3-step etch&rinse adhesives (3E&Ra's), 2-step etch&rinse adhesives (2E&Ra's), 2-step self-etch adhesives (2SEa's), 1-step self-etch adhesives (1SEa's), glass-ionomers (GI's) and self-adhesive composites (SAC's). The first four can bond restorative composite to tooth tissue. Both 2SEa and 1SEa were further sub-divided in 'mild' and 'intermediately strong (1/2SEa_m), with a pH≥1.5, and 'strong' (1/2SEa_s), with a pH<1.5. From the restoration retention rates as a function of time the average annual failure rate (AFR) per adhesive and adhesive class was calculated. RESULTS: The lowest AFR scores [mean (SD)] were recorded for GI [2.0 (1.4)] shortly followed by 2SEa_m [2.5 (1.5)], 3E&Ra [3.1 (2)] and 1SEa_m [3.6 (4.3)] (Tukey Contrasts: p>0.05). Significantly higher AFR scores were recorded for 1SEa_s [5.4 (4.8)], 2E&R [5.8 (4.9)], and 2SEa_s [8.4 (7.9)] (p>0.05). In addition, significant differences in AFR were noticed between adhesives of the same class (Kruskal-Wallis sum test: p>0.05), except for GI (p=0.7) and 2SEa_m (p=0.1). Finally, selective enamel etching did not significantly influence the retention rate of SEa (AFR SEa_etch=0.43 (0.49), AFR SEa_non-etch=1.43 (1.77). SIGNIFICANCE: The adhesive approach significantly influences the clinical effectiveness of adhesives in NCCLs. Within each class, except for GI, there was a wide variation in clinical bonding effectiveness.

Bonding of low-shrinking composites in high C-factor cavities.

OBJECTIVES: Polymerization shrinkage causes stress at the tooth-restoration interface. The magnitude of the stress depends upon several factors, such as the configuration factor (C-factor) of the cavity, the polymerization-conversion rate and filling technique. The aim of this study was to investigate the effect of curing time and filling method when high C-factor cavities were filled with low-shrinking composites. METHODS: Three low-shrinking (Filtek Silorane, 3M ESPE: FS; N'Durance, Septodont: N'D; Kalore, GC: Ka) and one conventional composite (Z100, 3M ESPE) were bonded into standardized occlusal Class-I cavities using either a two-step self-etch adhesive (Silorane System Adhesive, 3M ESPE: SSA) or a one-step self-etch adhesive (G-Bond, GC: GB). Five experimental groups were formed according to the employed adhesive/composite combination (SSA/FS, SSA/Z100, GB/N'D, GB/Ka, GB/Z100), and further divided into three subgroups conforming to curing time and filling technique (20 s/bulk; 80 s/bulk; 80 s/layered). For each subgroup, non-trimmed 1 mm×1 mm sticks were prepared from five teeth to measure the micro-tensile bond strength (µTBS) to cavity-bottom dentine. RESULTS: The two-step self-etch adhesive SSA generated higher bond strengths than the one-step self-etch adhesive GB, irrespective of the filling method. When GB was used, bulk filling with a low-shrinking composite revealed the highest bond strengths. For all composites, the layering method provided the highest bond strengths. SIGNIFICANCE: The two-step self-etch adhesive Silorane System Adhesive (3M ESPE) performed better than the one-step self-etch adhesive G-Bond (GC), regardless of the composite used. When the latter all-in-one adhesive was used, effects of shrinkage stress became more apparent.

Meta-analytical review of parameters involved in dentin bonding.

Bond-strength testing is the method most used for the assessment of bonding effectiveness to enamel and dentin. We aimed to disclose general trends in adhesive performance by collecting dentin bond-strength data systematically. The PubMed and EMBASE databases were used to identify 2,157 bond-strength tests in 298 papers. Most used was the micro-tensile test, which appeared to have a larger discriminative power than the traditional macro-shear test. Because of the huge variability in dentin bond-strength data and the high number of co-variables, a neural network statistical model was constructed. Variables like 'research group' and 'adhesive brand' appeared most determining. Weighted means derived from this analysis confirmed the high sensitivity of current adhesive approaches (especially of all-in-one adhesives) to long-term water-storage and substrate variability.

Current aspects on bonding effectiveness and stability in adhesive dentistry.

Improved dental adhesive technology has extensively influenced modern concepts in restorative dentistry. In light of minimal-invasive dentistry, this new approach promotes a more conservative cavity design, which basically relies on the effectiveness of current enamel-dentine adhesives. Nowadays, the interaction of adhesives with the dental substrate is based on two different strategies, commonly described as an etch-and-rinse and a self-etch approach. In an attempt to simplify the bonding technique, manufacturers have decreased the number of steps necessary for the accomplishment of the bonding procedure. As a consequence, two-step etch-and-rinse and one-step (self-etch) adhesives were introduced and gained rapid popularity in the dental market due to their claimed user-friendliness and lower technique sensitivity. However, many concerns have been raised on the bonding effectiveness of these simplified adhesives, especially in terms of durability, although this tends to be very material dependent. In order to blend all the adhesive components into one single solution, one-step adhesives were made more acidic and hydrophilic. Unfortunately, these properties induce a wide variety of seemingly unrelated problems that may jeopardize the effectiveness and stability of adhesion to the dental substrate. Being more susceptible to water sorption and thus nanoleakage, these adhesives are more prone to bond degradation and tend to fail prematurely as compared to their multi-step counterparts. Incidentally, another factor that may interfere with the bonding effectiveness of adhesives is the technique used for caries removal and cavity preparation. Several tools are on the market today to effectively remove carious tissue, thereby respecting the current trend of minimum intervention. Despite their promising performance, such techniques modify the tooth substrate in different aspects, possibly affecting bonding effectiveness. Altogether, we may conclude that not only the adhesive formulation, but also substrate nature must be taken into account to achieve a stable bonding interface, rendering the restorative treatment more predictable in terms of clinical performance. In this review, we analyse the current theoretical and clinical aspects of adhesion to enamel and dentine, and discuss the diverse possibilities to overcome problems which nowadays still challenge clinicians in their achievement of a more stable and effective bond to tooth enamel and dentine.

State of the art of self-etch adhesives.

This paper reflects on the state of the art of self-etch adhesives anno 2010. After presenting the general characteristics of self-etch adhesives, the major shortcomings of the most simple-to-use one-step (self-etch) adhesives are addressed. Special attention is devoted to the AD-concept and the benefit of chemical interfacial interaction with regard to bond durability. Finally, issues like the potential interference of surface smear and the more challenging bond to enamel for 'mild' self-etch adhesives are discussed.

Enamel-smear compromises bonding by mild self-etch adhesives.

In light of the increased popularity of less acidic, so-called 'ultra-mild' self-etch adhesives, adhesion to enamel is becoming more critical. It is hypothesized that this compromised enamel bonding should, to a certain extent, be attributed to interference of bur debris smeared across enamel during cavity preparation. High-resolution transmission electron microscopy revealed that the enamel smear layer differed not only in thickness, but also in crystal density and size, depending on the surface-preparation method used. Lab-demineralization of sections clearly disclosed that resin-infiltration of an ultra-mild self-etch adhesive progressed preferentially along micro-cracks that were abundantly present at and underneath the bur-cut enamel surface. The surface-preparation method significantly affected the nature of the smear layer and the interaction with the ultra-mild adhesive, being more uniform and dense for a lab-SiC-prepared surface vs. a clinically relevant bur-prepared surface.

Filler debonding & subhybrid-layer failures in self-etch adhesives.

The mechanisms behind bond degradation are still largely unknown, in particular with respect to self-etch adhesives. One-step adhesives have been especially documented with problems, such as insufficient polymerization, water-uptake and subsequent plasticization, water- and enzyme-induced nanoleakage, and/or the presence of voids due to phase-separation or osmosis. It was hypothesized that these shortcomings may weaken the adhesive layer and, as such, may jeopardize long-term bonding. In contrast to the control three-step etch & rinse adhesive, the bond strength to dentin of both one-step and two-step self-etch adhesives decreased after six-month water storage. TEM revealed not only that they exhibited filler de-bonding within the adhesive resin layer, due to hydrolysis of the filler-matrix coupling, but also that they failed predominantly directly under the hybrid layer at dentin, in spite of the presence of interfacial droplets and nanoleakage in the adhesive layer. These failures just under the hybrid layer may be attributed to insufficient encapsulation of surface smear.

The effect of clinical experience on dentine bonding effectiveness: students versus trained dentists.

Clinical successful application of dentine adhesives depends not only on material-related but also on operator-related factors. The purpose of this study was to evaluate the dentine bonding effectiveness of a self-etch composite cement applied by operators with or without clinical experience under well-standardized, randomized and blind conditions. Forty-eight bovine dentine surfaces were randomly divided into two groups. The first group consisted of eight dental students with no clinical experience at all, and the second group consisted of eight dentists with extensive experience in adhesive dentistry (mean experience of 11.4 years). Next, a 4-mm-diameter stainless steel rod (SUS-304) was bonded to the dentine surface using Panavia Fluoro cement (Kuraray Medical Inc., Tokyo, Japan). After application procedures, the specimens were randomized and shear bond-strength measurements were performed by a single blinded operator. Mann-Whitney U test was used to determine statistical differences in bond strength between the two groups, and Kruskal-Wallis was used to determine statistical difference between the student and dentist groups. The means and standard deviations of bond strength were 11.5 +/- 8.1 MPa for the student group and 7.1 +/- 4.3 MPa for the dentist group, respectively. The bond strength of the student group was significantly higher than that of the dentist group. However, the variability in bond strength was significantly higher in the student group, and some specimens failed prior to actual testing (included as 0 MPa). Clinical experience did not have a positive effect on the bonding effectiveness of the self-etch composite cement to dentine.

Hydrofluoric acid on dentin should be avoided.

UNLABELLED: Hydrofluoric acid can be used for intra-oral repair of restorations. Contamination of tooth substrate with hydrofluoric acid cannot always be avoided. OBJECTIVES: To investigate the bonding effectiveness to hydrofluoric acid contaminated dentin by, micro-tensile bond strength testing, SEM and TEM. METHODS: For this study, 15 molar teeth were used of which dentin surfaces were subjected to five, different etching procedures. Group A, 37.5% phosphoric acid (Kerr Gel) (control group); group B, 37.5% phosphoric acid followed by 3% hydrofluoric acid (DenMat); group C, 37.5% phosphoric acid, followed by 9.6% hydrofluoric acid (Pulpdent); group D, 3% hydrofluoric acid followed by 37.5%, phosphoric acid; group E, 9.6% hydrofluoric acid followed by 37.5% phosphoric acid. After the bonding procedure (OptiBond FL, Kerr) a composite resin build-up (Clearfil AP-X, Kuraray), was made. After 1 week storage, specimens were prepared for micro-tensile bond testing, SEM- and, TEM-analysis. Data were analyzed using ANOVA and post hoc Tukey's HSD (p<0.05). RESULTS: In the control group (solely phosphoric acid), the mean microTBS was 53.4+/-10.6 MPa, which was, significantly higher than any hydrofluoric acid prepared group (group A versus groups B-E, p<0.001). No, significant differences in microTBS were found between the 3% and 9.6% hydrofluoric acid groups: group B versus group C (13.5+/-5.5 MPa and 18.7+/-4.3 MPa, respectively) or group D versus group E (19.9+/-6.8 MPa and 20.3+/-4.1 MPa, respectively). SIGNIFICANCE: Due to its adverse effect on the bond strength of composite to dentin, contact of hydrofluoric acid to dentin should be avoided.

Impact of implant number, distribution and prosthesis material on loading on implants supporting fixed prostheses.

The purpose of this study is to evaluate axial forces and bending moments (BMs) on implants supporting a complete arch fixed implant supported prosthesis with respect to number and distribution of the implants and type of prosthesis material. Seven oral Brånemark implants with a diameter of 3.75 mm and a length of 13 and 7 mm (short distal implant) were placed in an edentulous composite mandible used as the experimental model. One all-acrylic, one fibre-reinforced acrylic, and one milled titanium framework prosthesis were made. A 50 N vertical load was applied on the extension 10 mm distal from the most posterior implant. Axial forces and BMs were measured by calculating signals from three strain gauges attached to each of the abutments. The load was measured using three different models with varying numbers of supporting implants (3, 4 and 5), three models with different implant distribution conditions (small, medium and large) and three models with different prosthesis materials (titanium, acrylic and fibre-reinforced acrylic). Maximum BMs were highest when prostheses were supported by three implants compared to four and five implants (P < 0.001). The BMs were significantly influenced by the implant distribution, in that the smallest distribution induced the highest BMs (P < 0.001). Maximum BMs were lowest with the titanium prosthesis (P < 0.01). The resultant forces on implants were significantly associated with the implant number and distribution and the prosthesis material.

Relationship between bond-strength tests and clinical outcomes.

One often alleges that laboratory bond-strength testing cannot predict clinical effectiveness of adhesives. Major argument to sustain this claim is the wide variation in bond-strength values recorded for one specific adhesive among different research institutes worldwide. The main reason for these inconsistent bond-strength measurements is supposedly the current lack of a standard bond-strength testing protocol. This paper (and presentation) aimed to report on an extensive literature review with regard to the different laboratory bond-strength test methods and their data provided, along with a second extensive literature review on clinical effectiveness data of adhesives in terms of retention rates of adhesive Class-V restorations. Combining both systematic reviews, we have subsequently searched for a potential relationship between bond-strength data and clinical outcomes.

Inhibition of enzymatic degradation of adhesive-dentin interfaces.

Adhesive procedures activate dentin-associated matrix metalloproteinases (MMPs), and so iatrogenically initiate bond degradation. We hypothesized that adding MMP inhibitors to adhesive primers may prevent this endogenous enzymatic degradation, thereby improving bond durability. A non-specific MMP inhibitor (chlorhexidine) and a MMP-2/9-specific inhibitor (SB-3CT) were admixed to the primers of an etch & rinse and a self-etch adhesive, both considered as gold-standard adhesives within their respective categories. For dentin powder exposed to the adhesives under clinical application conditions, gelatin zymography revealed the release of MMP-2 (not of MMP-9) by the etch & rinse adhesive, while no release of enzymes could be detected for the mild self-etch adhesive, most likely because of its limited dentin demineralization effect. The built-in MMP inhibitors appeared effective in reducing bond degradation only for the etch & rinse adhesive, and not for the self-etch adhesive. Water sorption of adhesive interfaces most likely remains the principal mechanism of bond degradation, while endogenous enzymes appear to contribute to bond degradation of only etch & rinse adhesives.

Technique sensitivity of water-free one-step adhesives.

OBJECTIVES: All-in-one adhesives have been associated with water-related problems, such as phase-separation, polymerization-inhibition and reduced shelf life. In this study we investigated whether these problems could be avoided by a water-free self-etch adhesive that requires a 'wet-bonding' application procedure. Additionally, the technique-sensitivity of such a system was evaluated. METHODS: The micro-tensile bond strength (muTBS) of a water-free and a water-containing experimental one-step adhesive (EXP) bonded to either 'air-dried', 'blot-dried' or 'overwet' bur-cut enamel and dentin was determined. Likewise, the muTBS of a commercial water-free adhesive Absolute2 (Denstply-Sankin) was determined. The interfacial interaction of the adhesives was evaluated by SEM and TEM. RESULTS: In the blot-dried group, both water-free adhesives obtained the highest bond strength and the bond strength of the water-free EXP was comparable to that of the water-containing EXP bonded to an air-dried surface. When they were applied to overwet surfaces, the water-free adhesives tended towards a lower bond strength. This was partly attributed to the presence of phase-separation (or 'overwet') droplets in the adhesive layer. Unexpectedly, even on air-dried dentin, the water-free adhesives were able to demineralize dentin, however to a limited extent, hence impairing the bond strength. SIGNIFICANCE: Water-free one-step adhesives are a valuable alternative for conventional water-containing one-step adhesives. However, water-related problems in these adhesives are not ruled out, as they are eventually also mixed with water during the application procedure. As such, they partially fail to meet their objective. In addition, their bonding procedure, which involves 'wet bonding', is more technique-sensitive than dry bonding.