Effect of preparation design and endodontic access on fracture resistance of zirconia overlays in mandibular molars: An in vitro study.

PURPOSE: To evaluate the fracture resistance of zirconia overlays, considering various preparation designs and the presence of endodontic access. MATERIALS AND METHODS: Ninety translucent zirconia (5Y-PSZ) overlay restorations were divided into six groups (n = 15/group) based on different preparation designs, with and without endodontic access: chamfer margin 4 mm above the gingival level without (group 1) and with endodontic access (group 2); margin 2 mm above the gingival level without (group 3) and with endodontic access (group 4); overlay with no chamfer margin without (group 5) and with endodontic access (group 6). Restorations were bonded to mandibular first molar resin dies, and the groups with endodontic access were sealed with flowable resin composite. All restorations underwent 100,000 cycles of thermal cycling between 5°C and 55°C, followed by loading until fracture. Maximum load and fracture resistance were recorded. ANOVA with Tukey post-hoc tests were used for statistical comparison (α < 0.05). RESULTS: Fracture resistance significantly varied among overlay designs with and without endodontic access (p < 0.001), except for the no-margin overlays (groups 5 and 6). Overlays with a 2 mm margin above the gingival margin with endodontic access (group 4) exhibited significantly higher fracture resistance compared to both the 4-mm supragingival (group 2) and no-margin (group 6) designs, even when compared to their respective intact groups (groups 1 and 5). There were no significant differences between the no-margin and 4-mm supragingival overlays. CONCLUSION: The more extensive zirconia overlay for mandibular molars is the first choice since the 2 mm margin above the gingival level design withstood considerable loads even after undergoing endodontic access. A no-margin overlay is preferred over the 4-mm supragingival design as it preserves more tooth structure and there was no outcome difference, irrespective of endodontic access. Caution is warranted in interpreting these findings due to the in vitro nature of the study.

The Accuracy of Post and Core Fabricated with Digital Technology.

PURPOSE: To compare the accuracy of post and cores created with three different fabricating techniques: direct conventional, machine milling, and three-dimensional (3D) printing. MATERIALS AND METHODS: Thirteen extracted single root central incisors were selected. Root canal treatment and tooth preparation for crown were performed on all teeth. Post space preparation of 11 mm was created using prefabricated fiber post drill to standardize post space width and length. Root canal impressions were performed on all teeth using polyvinyl siloxane impression material. Each impression was then three dimensionally scanned using an extraoral lab scanner. The scanned impressions were used to design digital files of post and cores with 3Shape CAD software. The digitally designed post and cores were used to fabricate 3D printed and milled post and core resin patterns. The same teeth were used to fabricate post and core with conventional technique (direct duplication of root canal with resin pattern). All posts were then scanned before being invested and then cast using base metal educational alloy. The metal post and cores were tried in with sample teeth and manually adjusted until found to be clinically acceptable. The post and cores were scanned in different stages to perform digital volume measurement using Geomagic Control software to determine accuracy. Pairwise comparisons were accomplished using exact version of the sign test (α = 0.05). RESULTS: These three techniques of post and core fabrication showed different results in the various stages of fabrication. The accuracy of 3D printed resin pattern (26.89 ±11.09 mm3 ) was found to be inferior compare to milled resin pattern (28.20 ±11.41 mm3 , p = 0.0002). However, dimensional stability of the 3D printed resin pattern before and after casting (0.56 ±0.95 mm3 ) was found to be superior to milled resin pattern (0.79 ±0.89 mm3 ) and direct resin pattern (2.51 ±1.38 mm3 , p = 0.00002). All three techniques showed significant volume reduction after adjustment (p = 0.0002). In the final stage, the adjusted metal post and core fabricated with three different techniques showed no statistical different in accuracy (p = 0.15). CONCLUSION: Digitally fabricated post and cores have the same degree of accuracy as those fabricated using the gold standard direct conventional post and core technique.

The accuracy comparison of 3D-printed post and core using castable resin and castable wax resin.

PURPOSE: The purpose of this research was to compare the accuracy of three-dimensionally (3D) printed post and core fabricated with two different materials: reinforced wax and castable resin. MATERIALS AND METHODS: Fifteen extracted single root central incisors were selected. Root canal treatment and tooth preparation for crown were performed on all teeth. Eleven millimeters post space was created with standardized prefabricated fiber post drill. Polyvinylsiloxane impression material was used for root canal impressions. Each impression was then 3D scanned using an extraoral scanner and cast posts and cores were designed using 3Shape software. The digitally designed post and cores were 3D printed with two different materials: castable wax resin and castable resin. The castable resin patterns were scanned before and after complete polymerization. The wax patterns were also scanned. Digital volumetric measurement using Geomagic® Control X™ software was performed to determine accuracy. RESULTS: The printed post and core had reduced volume (16.09 ± 3.839 mm3 ) compared to the digital design (17.828 ± 3.904, p < 0.05). Before complete polymerization, the accuracy of 3D printed resin pattern (16.464 ± 3.017) was found to be superior to post and core printed with wax (16.193 ± 3.018, p < 0.05). However, no volume difference was found between completely polymerized resin (16.09 ± 3.839) and wax (16.044 ± 3.834, p = 1). CONCLUSION: 3D printed post and core showed significant volume shrinkage from the digital files used to create them. However, different materials had no effect on the accuracy of 3D printed post and core.

Children's Hospital Ambulatory Response to the 2019 Novel Coronavirus Disease (COVID-19) Pandemic.

The 2019 novel coronavirus disease (COVID-19) pandemic produced an abrupt and near shutdown of nonemergent patient care. Children's National Hospital (CNH) mounted a multidisciplinary, coordinated ambulatory response that included supply chain management, human resources, risk management, infection control, and information technology. To ensure patient access, CNH expanded telemedicine and instituted operational innovations for outpatient procedures. While monthly in-person ambulatory subspecialty visits decreased from 25 889 pre-COVID-19 to 4484 at nadir of the COVID-19 pandemic, telemedicine visits increased from 70 to 13 539. Further studies are needed to assess the impact of innovations in health care delivery and operations that the crisis prompted.

In vitro evaluation of the marginal integrity of CAD/CAM interim crowns.

STATEMENT OF PROBLEM: The accuracy of interim crowns made with computer-aided design and computer-aided manufacturing (CAD/CAM) systems has not been well investigated. PURPOSE: The purpose of this in vitro study was to evaluate the marginal integrity of interim crowns made by CAD/CAM compared with that of conventional polymethylmethacrylate (PMMA) crowns. MATERIAL AND METHODS: A dentoform mandibular left second premolar was prepared for a ceramic crown and scanned for the fabrication of 60 stereolithical resin dies, half of which were scanned to fabricate 15 Telio CAD-CEREC and 15 Paradigm MZ100-E4D-E4D crowns. Fifteen Caulk and 15 Jet interim crowns were made on the remaining resin dies. All crowns were cemented with Tempgrip under a 17.8-N load, thermocycled for 1000 cycles, placed in 0.5% acid fuschin for 24 hours, and embedded in epoxy resin before sectioning from the mid-buccal to mid-lingual surface. The marginal discrepancy was measured using a traveling microscope, and dye penetration was measured as a percentage of the overall length under the crown. RESULTS: The mean vertical marginal discrepancy of the conventionally made interim crowns was greater than for the CAD/CAM crowns (P=.006), while no difference was found for the horizontal component (P=.276). The mean vertical marginal discrepancy at the facial surface of the Caulk crowns was significantly greater than that of the other 3 types of interim crowns (P<.001). At the facial margin, the mean horizontal component of the Telio crowns was significantly larger than that of the other 3 types, with no difference at the lingual margins (P=.150). The mean percentage dye penetration for the Paradigm MZ100-E4D crowns was significantly greater and for Jet crowns significantly smaller than for the other 3 crowns (P<.001). However, the mean percentage dye penetration was significantly correlated with the vertical and horizontal marginal discrepancies of the Jet interim crowns at the facial surface and with the horizontal marginal discrepancies of the Caulk interim crowns at the lingual surface (P<.01 in each instance). CONCLUSIONS: A significantly smaller vertical marginal discrepancy was found with the interim crowns fabricated by CAD/CAM as compared with PMMA crowns; however, this difference was not observed for the horizontal component. The percentage dye penetration was correlated with vertical and horizontal discrepancies at the facial surface for the Jet interim crowns and with horizontal discrepancies at the lingual surface for the Caulk interim crowns.

Clinical acceptability of crown margins versus marginal gaps as determined by pre-doctoral students and prosthodontists.

PURPOSE: Marginal integrity is a very important element in evaluating a restoration; however, there is no agreement in definition of a clinically acceptable margin. The purpose of this investigation was to examine margin acceptability using an explorer versus the actual marginal gap widths at four locations on uncemented crowns on three extracted teeth using both predoctoral students and prosthodontists as evaluators. MATERIALS AND METHODS: The crown margin evaluation used 16 surfaces of four crowns fitting to three extracted caries-free teeth fitted into a dentiform. The teeth (nos. 14, 20, and 29) were prepared for a full cast (gold) crown using a chamfer finish line configuration, with some margins supragingival and others subgingival. After final impressions and working casts were made, die spacer was applied to the marginal area of the die before waxing to vary the marginal opening. The dentiform was placed in a mannequin in a supine position. Predoctoral students (N = 10) and prosthodontists (N = 9) evaluated each axial surface of each crown in the zone along the margin with an explorer and rated each surface as either "clinically acceptable" or "unacceptable." After casting, the axial marginal openings were measured with Image Pro Software using a digital microscopic image of the surface. Each participant repeated the margin evaluations 6 months later. RESULTS: Upon casting, marginal gaps ranged from 40 microm to 615 microm. The proportions of prosthodontists and of predoctoral students rating a given surface as "clinically unacceptable" were highly correlated (Spearman rank correlation = 0.81, p= 0.0001). The prosthodontists did not provide more or fewer ratings of clinical acceptability than the students, although kappa results indicated that the prosthodontists might be more consistent among themselves than the student raters. Upon re-evaluation, both groups rated between one and six of the surfaces differently than they had previously: the median number of inconsistencies was 1 for prosthodontists and 3 for predoctoral students. The prosthodontists tended to have fewer inconsistencies than the predoctoral students (0.05 < p < 0.10 Wilcoxon rank sum test), but this was not statistically significant. CONCLUSION: The data provided evidence that those surfaces associated with greater margin gaps tended to have a greater proportion of ratings of "clinically unacceptable." The proportion of prosthodontists and predoctoral students rating a margin "clinically unacceptable" were highly correlated. Prosthodontists tended to have fewer inconsistencies than predoctoral students, but that difference was not statistically significant.

Alterations of surface hardness with gypsum die hardeners.

STATEMENT OF PROBLEM: Die stones require abrasion resistance, dimensional stability with time, and high surface wettability material properties. PURPOSE: The purpose of this study was to compare the surface microhardness (Knoop) of 4 contemporary gypsum materials with and without surface die hardener. MATERIAL AND METHODS: Materials used were a Type III stone (Microstone) and 3 die stones (Die-Keen, Silky-Rock, and ResinRock). Die hardener was cyanoacrylate (Permabond 910) or Clear Coat. Specimens of stone were hand mixed with distilled room temperature water and vacuum spatulated according to manufacturer's directions. Five cylinders (15 x 15 mm) per group were poured, using vibration, into phenolic ring molds positioned on top of a glass slide. The face of each specimen was polished with 2400-grit Al2O sandpaper. One face of each of 5 specimens/material was coated with cyanoacrylate; 5 specimens/material were coated with Clear Coat, air thinned and dried; and 5 specimens/material had no treatment (control). Knoop hardness (kg/mm2) readings were made on each face (5 readings/time point) 3, 12, and 24 hours after pouring. An ANOVA procedure with post hoc Tukey tests were performed (alpha=.05). RESULTS: Microhardness did not vary between 3 and 24 hours for any material (P>.05). Microstone had significantly lower surface hardness (P<.0001) than the die stones. Specimens coated with die hardener had lower hardness values (P<.001 in all cases) CONCLUSIONS: The 3 types of die stones evaluated in this study did not differ significantly in surface microhardness. Under these conditions, die hardener coatings reduced the surface hardness of the gypsum material.

Comparison of the dimensional accuracy of injection-molded denture base materials to that of conventional pressure-pack acrylic resin.

PURPOSE: This study compared the linear dimensional changes of 3 injection-molded denture base materials to that of conventionally processed polymethylmethacrylate (PMMA) resin. MATERIALS AND METHODS: An impression of an aluminum maxillary edentulous arch was made with a condensation silicone impression material (Denture Elasticon) to fabricate a gypsum master cast that was replicated as a silicone mold. A maxillary complete denture with acrylic teeth was waxed to full contour on the master cast and replicated to make 40 wax dentures. ERA attachments cast in metal (Rexillium) with indices milled into the centers were waxed into 3 positions in each denture for recording dimensional measurements of the wax denture. Ten dentures were allocated to each of 4 groups; Group 1 was processed using conventionally processed PMMA (Microlon), Group 2 used injection-molded PMMA (SR-lvocap), Group 3 employed injection-molded nylon (Valplast), and Group 4 used injection-molded styrene (Northern). All processed specimens were stored at room temperature (25 degrees C, ambient humidity) for 1 week (while still on the master cast) before anteroposterior and cross-arch measurements were made using the ERA reference points with a digital caliper. After separation from the master cast and following water storage at 37 degrees C for 7 days additional measurements were made. RESULTS: An analysis of the results showed that the effect of processing was not the same for the 3 dimensions studied, regardless of which dimension was considered (p < 0.0001). The pattern of dimensional changes associated with the material type was not the same between the wax and processing stages as it was for the change between the processing and decasting stages (p < 0.0001). CONCLUSIONS: Processing the denture base materials produced unequal deformation in different dimensions (anterior-posterior and cross-arch). Each material tested also responded differently to the processing stages.

Influence of surface hardener on gypsum abrasion resistance and water sorption.

STATEMENT OF PROBLEM: Abrasion is a major concern when gypsum products are used for dies, leading to the frequent recommendation that surface hardeners should be used before waxing or scanning. PURPOSE: This study evaluated abrasion resistance and water sorption with 4 commonly used gypsum die materials with and without the application of surface die hardeners. MATERIAL AND METHODS: Three ADA Type IV (Vel-Mix, ResinRock, and Silky-Rock) and 1 Type V die material (Die-Keen) were evaluated for abrasion resistance after application of 2 surface hardeners (Permabond 910 cyanoacrylate and Clear Coat). Thirty specimens of each material were fabricated using an impression of a standard brass die machined with 1-mm high ridges, sloped 45 degrees. Gypsum materials were mixed according to manufacturers' recommendations and allowed to set 1 hour before separating. All replicated dies were allowed to bench set for 14 days before testing. One hour before testing, specimens were arbitrarily assigned to 1 of 3 treatment subgroups (n=10/group): no treatment (control), coated with Permabond 910, or coated with Clear Coat. In the coated groups, die hardener was painted over the grooves and air dried. Abrasion resistance (measured by weight loss) was evaluated using a reciprocal abrasion device in which a stylus applied a 50-g mass perpendicular to the ridges. Mass loss was determined using an analytical balance before and after each test cycle. Five sets of 20 unidirectional passes were made on each specimen. A scanning electron microscope was used to evaluate the surface of specimens in each treatment subgroup. Water sorption was also evaluated using 2 Type IV (Silky-Rock, ResinRock) and 1 Type III (Microstone) gypsum materials. Specimen dies were separated 1 hour after pouring the impression and allowed to bench set 1 week before testing. Five specimens from each material group received a coating of a surface hardener 1 hour before testing. Specimens were placed in distilled water for 15 minutes and differences in mass were determined using an analytical balance before and after each test. A 2-way analysis of variance was completed followed by a Tukey post hoc test (alpha=.05). RESULTS: The 2-way analysis of variance revealed an interaction between product and surface coating (P=.0459). Given this interaction, the 12 combinations determined by surface treatment and material type were considered individually using the Tukey method. Vel-Mix, control (2.62 +/- 2.64 mg) had the most material loss and Vel-Mix, Clear Coat (0.48 +/- 0.29 mg) had the least material loss. Water sorption results indicated an interaction between the gypsum material and the surface treatment (P<.0001). The control groups of Microstone (299.2 +/- 49.6 mg) and Silky-Rock (159.0 +/- 8.5 mg) showed the most water sorption compared with the other treatment groups. CONCLUSIONS: This study demonstrated that a significant improvement in abrasion resistance occurred only with specific gypsum/surface hardener material combinations. Also, water sorption decreased significantly for Microstone and Silky-Rock gypsum materials when a surface hardener was used.

The complexities involved with managing the care of an elderly patient.

BACKGROUND: Treatment planning for and managing the care of elderly patients can be complicated for a number of reasons. To understand the patient's needs, one must understand the environment in which the patient functions. CASE DESCRIPTION: The authors present a case that illustrates some of the social, economic, financial and transportation issues that are involved in treating elderly patients, as well as how the dynamics of the interpersonal relationships influence the final treatment. CLINICAL IMPLICATIONS: A dental treatment plan can be difficult to outline to a patient because modifying factors may make care complex and difficult to manage. This requires good communication among the dentist, patient and family.

Abrasion resistance of a resin-impregnated type IV gypsum in comparison to conventional products.

STATEMENT OF PROBLEM: Limited abrasion resistance is one of the disadvantages of gypsum materials. One means to improve these properties may be the addition of various polymers to reinforce surface and subsurface wear resistance. PURPOSE: The purpose of this study was to evaluate the abrasion resistance of 3 types of gypsum materials with a novel abrasion wear device. MATERIAL AND METHODS: A standard test specimen (50 x 50 x 8 mm) with repeating 1 mm, 45 degrees -angle vertical ridges was used as the test surface. Three types of gypsum materials were evaluated: a type III stone, a conventional type IV stone, and a resin-impregnated type IV stone. Specimens of each material (n = 30) were poured in a vinyl polysiloxane impression of the standard test specimen with the use of an acrylic resin custom tray. Each gypsum product was mixed according to the manufacturer's instructions, poured, and separated 1 hour later. Specimens were trimmed and allowed to bench set for 24 hours (n = 15) or 7 days (n = 15). Abrasion was evaluated with the use of a reciprocal moving stage positioned below a weighted stylus. The stylus was loaded with 3 different weights (15, 50, and 75 g), and the individual gypsum specimens were moved reciprocally for 10 passes. Before and after each set of passes, the specimen was measured on an analytical balance to determine material loss. Three-way ANOVA and Scheffe's multiple comparisons test were used to analyze the data (P<.05). RESULTS: Type III gypsum at 24 hours exhibited significantly greater material loss than type IV stones at both 7 days and 24 hours (P<.001). Type III gypsum specimens exhibited significantly greater material loss at 24 hours than at 7 days (P<.001). There was no significant difference in the abrasion resistance of type IV specimens at 24 hours and 7 days. CONCLUSION: Within the limitations of this study, no significant differences in abrasion resistance were found between specimens fabricated with resin-impregnated and conventional type IV stones, although the former exhibited the least material loss.

A comparison of student performance in a simulation clinic and a traditional laboratory environment: three-year results.

With simulation clinics, dental schools have improved their preclinical laboratories to provide a more realistic clinical teaching environment. However, there is very little data to support the assumption that these facilities actually improve student performance of technical skills. This study compared the scores of two fixed preparations for full cast crowns by third-year dental students. One of the preparations was made in the simulation clinic manikin, and the other was prepared on the bench top. Three prosthodontic faculty members scored the preparations in the areas of occlusal reduction, axial reduction, resistance and retention, and margination. The study also compared the performance of three classes of dental students: one class with no experience in the simulation clinic, one with one year of experience, and one with two years of experience. The amount of time since completing the fixed prosthodontics course among the students was also evaluated. This was done because the third-year students at the University of Iowa rotate through a series often-week clerkships rather than a comprehensive care model. (Therefore, not all students start clinical prosthodontics at the same time.) In addition, all student participants completed a questionnaire that addressed their perception of their clinical readiness prior to treating their first fixed prosthodontic patient. When we compared the classes of years 1, 2, and 3 by average preparation score, we found a significant difference among the scores for teeth prepared on the bench top (p = 0.0001) but not for the teeth prepared in the mannequin (p = 0.1176). For Year 1 (no simulation clinic experience), the amount of elapsed time following completion of the fixed prosthodontic course was not significant for the tooth prepared on the bench top or in the manikin (p = 0.57113 and 0.0661). For Year 2 (one year of simulation clinic experience), the elapsed time following completion of the fixed prosthodontic course was significant for the tooth prepared on the bench top (p = 0.0482), but it was not significant for the tooth prepared in the manikin (p = 0.2968). For Year 3 (two years of simulation clinic experience), the amount of elapsed time following completion of the fixed prosthodontic course was not significant for the tooth prepared on the bench top or in the manikin (p = 0.7275 and 0.6007). The questionnaire revealed that, in general, the majority of the students perceived their clinical readiness as more than adequate. These results are mixed in that students with more bench top experience scored better on the bench top, and students with more manikin experience scored equally in both environments.