Minimally invasive CAD/CAM lithium disilicate partial-coverage restorations show superior in-vitro fatigue performance than single crowns.

OBJECTIVE: To analyze the influence of restoration design (partial-coverage restoration vs. crown) and ceramic layer thickness on the performance and failure loads of CAD/CAM-fabricated lithium disilicate (LDS) reconstructions on molars after fatigue. MATERIALS AND METHODS: Seventy-two posterior monolithic CAD/CAM-fabricated LDS restorations (IPS e.max CAD, Ivoclar Vivadent) with different occlusal/buccal ceramic layer thicknesses (1.5/0.8, 1.0/0.6, and 0.5/0.4 mm) and restoration designs (PCR: non-retentive full-veneer/partial-coverage restoration, C: crown,) were investigated and divided into six groups (n = 12, test: PCR-1.5, PCR-1.0, PCR-0.5; control: C-1.5, C-1.0, C-0.5). LDS restorations were adhesively bonded (Variolink Esthetic DC, Ivoclar Vivadent) to dentin-analogue composite dies (Z100, 3M ESPE). All specimens were subjected to thermomechanical loading (1.2 million cycles, 49 N, 1.6 Hz, 5-55°C) and exposed to single load to failure testing. Failure analysis was performed with light and scanning electron microscopies. Data were statistically analyzed using ANOVA, Tukey-Test, and t-test (p < 0.05). RESULTS: Eight crown samples (C-0.5) and one PCR specimen (PCR-0.5) revealed cracks after fatigue, resulting in an overall success rate of 87.5% (crowns: 75%, PCRs: 96.88%). Direct comparisons of PCRs versus crowns for thicknesses of 0.5 mm (p < 0.001) and 1.0 mm (p = 0.004) were significant and in favor of PCRs. Minimally invasive PCRs (0.5 and 1.0 mm) outperformed crowns with the identical ceramic thickness. No difference was detected (p = 0.276) between thickness 1.5 mm PCRs and crowns. CONCLUSIONS: Minimally invasive monolithic CAD/CAM-fabricated posterior LDS PCRs (0.5 and 1.0 mm) resulted in superior failure load values compared to minimally invasive crowns. Minimally invasive crowns (0.5 mm) are prone to cracks after fatigue. CLINICAL SIGNIFICANCE: Minimally invasive CAD/CAM-fabricated LDS PCR restorations with a non-retentive preparation design should be considered over single crowns for molar rehabilitation.

Group 2 ITI Consensus Report: Technological developments in implant prosthetics.

OBJECTIVES: Group-2 reviewed the scientific evidence in the field of «Technology¼. Focused research questions were: (1) additive versus subtractive manufacturing of implant restorations; (2) survival, complications, and esthetics comparing prefabricated versus customized abutments; and (3) survival of posterior implant-supported multi-unit fixed dental prostheses. MATERIALS AND METHODS: Literature was systematically screened, and 67 publications could be critically reviewed following PRISMA guidelines, resulting in three systematic reviews. Consensus statements were presented to the plenary where after modification, those were accepted. RESULTS: Additively fabricated implant restorations of zirconia and polymers were investigated for marginal/internal adaptation and mechanical properties without clear results in favor of one technology or material. Titanium base abutments for screw-retained implant single crowns compared to customized abutments did not show significant differences concerning 1-year survival. PFM, veneered and monolithic zirconia implant-supported multi-unit posterior fixed dental prostheses demonstrated similar high 3-year survival rates, whereas veneered restorations exhibited the highest annual ceramic fracture and chipping rates. CONCLUSIONS: For interim tooth-colored implant single crowns both additive and subtractive manufacturing are viable techniques. The clinical performance of additively produced restorations remains to be investigated. Implant single crowns on titanium base abutments show similar clinical performance compared to other type of abutments; however, long-term clinical data from RCTs are needed. The abutment selection should be considered already during the planning phase. Digital planning facilitates 3D visualization of the prosthetic design including abutment selection. In the posterior area, monolithic zirconia is recommended as the material of choice for multi-unit implant restorations to reduce technical complications.

Influence of straight versus angulated screw channel titanium bases on failure loads of two-piece ceramic and titanium implants restored with screw-retained monolithic crowns: An in-vitro study.

OBJECTIVE: To analyze the influence of titanium-base (straight [SSC]/angulated-screw-channel [ASC]) on failure-loads and bending-moments of two-piece ceramic and titanium-zirconium implants restored with monolithic-zirconia crowns after fatigue. MATERIALS AND METHODS: Thirty-two anterior monolithic-screw-retained zirconia crowns were divided into four groups (n = 8/group) according to the factors: (1) type of implant material: two-piece titanium-zirconium implant (Ti-Zr; control-group) versus two-piece ceramic implant (CI; test-group) and (2) type of titanium-base: SSC (0° angle) versus ASC (25°). An intact implant was used for field emission gun-scanning electronic microscopy (FEG-SEM) characterization and Raman spectroscopy for phase analyses and residual stress quantification. All samples were exposed to fatigue with thermodynamic loading (1.2-million-cycles, 49 N, 1.6 Hz, 5-55°C) at a 30° angle. Surviving specimens were loaded until failure (SLF) and bending moments were recorded. Failed samples were examined using light microscope and SEM. Statistical analyses included ANOVA and Mann-Whitney U-test. RESULTS: Raman-spectroscopy revealed the presence of residual compressive stresses. FEG-SEM revealed a roughened surface between threads and polished surface at the cervical-collar of the ceramic implant. All samples survived fatigue and were free of complications. Mean bending-moments (±SD) were: Ti-Zr-0: 241 ± 45 N cm, Ti-Zr-25: 303 ± 86 N cm, CI-0: 326 ± 58 N cm, CI-25: 434 ± 71 N cm. Titanium-base and implant-material had significant effects in favor of ASC titanium bases (p = .001) and ceramic-implants (p < .001). Failure analysis after SLF revealed severe fractures in ceramic implants, whereas titanium implants were restricted to plastic deformation. CONCLUSIONS: Ceramic and titanium implants exhibited high reliability after fatigue, with no failures. From a mechanical perspective, titanium bases with ASC can be recommended for both ceramic and titanium implants and are safe for clinical application.

Failure Load of Monolithic Lithium Disilicate Implant-Supported Single Crowns Bonded to Ti-base Abutments versus to Customized Ceramic Abutments after Fatigue.

PURPOSE: This laboratory study analyzed the influence of retention mode (screw- vs cement retained) and fatigue application on the failure load of monolithic lithium-disilicate (LDS) implant-supported single crowns (ISSC). MATERIAL AND METHODS: A total of 72 samples of monolithic LDS (*Ivoclar Vivadent) ISSC were divided into three groups (n = 24) according to their type of retention mode: Group Ti-CAD: Titanium base (SICvantage CAD/CAM Abutment red (SIC invent AG), screw-retained milled monolithic LDS (IPS e.max CAD*); Group Ti-P: Titanium base (SICvantage CAD/CAM Abutment red), screw-retained pressed monolithic LDS (IPS e.max Press*) and Group Ti-Cust: Titanium base with cemented press LDS (IPS e.max Press*) crown on a LDS (IPS e.max Press*) custom abutment. A mandibular first molar implant-supported single crown model was investigated (Titanium implant: SICvantage-max, SIC invent AG, diameter: 4.2 mm, length: 11.5 mm). Half of each group (n = 12) w​ere exposed to fatigue with cyclic mechanical loading (F = 198 N, 1.2 million cycles) and simultaneous thermocycling (5-55°C). Single load to failure testing was performed, before (Subgroups Ti-CAD, Ti-P, and Ti-Cust) and after (Subgroups Ti-CAD-F, Ti-P-F, and Ti-Cust-F) fatigue. Weibull distribution was used to determine the characteristic strength and Weibull modulus differences between groups. Probability of survival at 900N load was calculated. RESULTS: No samples failed during fatigue. Characteristic strength values were as follow: Ti-CAD: 3259.5N, Ti-CAD-F: 2926N, Ti-P: 2763N, Ti-P-F: 2841N, Ti-Cust: 2789N, Ti-Cust-F: 2194N. Whereas no difference was observed between pressed or milled monolithic crowns cemented to Ti-base, regardless of loading condition, fatigue decreased the characteristic strength of crowns cemented to custom abutments. Probability of survival at 900 N was not significantly different between groups. CONCLUSIONS: Screw-retained pressed or milled monolithic LDS ISSC, cemented directly to Ti-base abutments or LDS crowns cemented to custom ceramic abutments resist physiological chewing forces after simulated 5-year aging in the artificial mouth and presented equally high probability of survival. However, a significant decrease in load to failure was observed in LDS crowns cemented to custom ceramic abutments after fatigue. Prospective clinical trials are needed to confirm the results of this laboratory investigation.

CAD/CAM Ceramic Restorative Materials for Natural Teeth.

Advances in computer-aided design (CAD) / computer-aided manufacturing (CAM) technologies and their ease of application enabled the development of novel treatment concepts for modern prosthodontics. This recent paradigm shift in fixed prosthodontics from traditional to minimally invasive treatment approaches is evidenced by the clinical long-term success of bonded CAD/CAM glass-ceramic restorations. Today, defect-oriented restorations, such as inlays, onlays, and posterior crowns, are predominately fabricated from glass-ceramics in monolithic application. The variety of CAD/CAM ceramic restorative systems is constantly evolving to meet the increased demands for highly aesthetic, biocompatible, and long-lasting restorations. Recently introduced polymer-infiltrated ceramic network CAD/CAM blocks add innovative treatment options in CAD/CAM chairside 1-visit restorations. The material-specific high-edge stability enables the CAD/CAM machinability of thin restoration margins. Full-contour zirconia restorations are constantly gaining market share at the expense of bilayered systems. Advancements in material science and bonding protocols foster the development of novel material combinations or fabrication techniques of proven high-strength zirconia ceramics. CAD/CAM applications offer a standardized manufacturing process resulting in a reliable, predictable, and economic workflow for individual and complex teeth-supported restorations. More evidence from long-term clinical studies is needed to verify the clinical performance of monolithic polymer-infiltrated ceramic network and zirconia teeth-supported minimally invasive and extensive restorations.

Polymer-infiltrated ceramic CAD/CAM inlays and partial coverage restorations: 3-year results of a prospective clinical study over 5 years.

OBJECTIVE: The aim of this prospective clinical 5-year study was to evaluate the long-term behavior of monolithic computer-aided design and computer-aided manufacturing (CAD/CAM)-fabricated minimally invasive polymer-infiltrated ceramic network (PICN) inlays and partial coverage restorations (PCR). MATERIAL AND METHODS: Posterior teeth of 47 patients were restored with 103 restorations (45 inlays, 58 PCRs). After defect-oriented preparations, monolithic PICN restorations of VITA Enamic were fabricated with a CAD/CAM system (inEoS blue/CEREC inLab MCXL) and adhesively bonded (Variolink II). Clinical reevaluations were so far performed at baseline and 6, 12, 24, and 36 months after insertion according to modified United States Public Health Service (USPHS) criteria. Absolute failures were demonstrated by Kaplan-Meier survival rate and relative failures by Kaplan-Meier success rate. A logistic regression model was adjusted for modified USPHS criteria to investigate time and restoration effects (p < 0.05). RESULTS: After an observation time of 3 years, survival rates were 97.4% for inlays and 95.6% for PCRs. Three restorations had to be replaced due to clinically unacceptable fractures. Secondary caries and debonding were not observed. The 3-year Kaplan-Meier success rate was 84.8% for inlays and 82.4% for PCRs. The decrease in marginal adaption (p = 0.0005), increase in marginal discoloration (p < 0.0001), and surface roughness (p = 0.0005) over time were significant. Color match and anatomic form were excellent. No significant differences were found between both types of restorations for survival (p = 0.716) and success rate (p = 0.431). CONCLUSIONS: Minimally invasive PICN restorations showed a favorable clinical performance over an observation period of 36 months. However, clinical long-term data have to be awaited. CLINICAL RELEVANCE: PICN restorations are a suitable treatment option for posterior inlays and PCRs.