Alain Vanheusden

Clinical risk factors related to failures with zirconia-based restorations: An up to 9-year retrospective study

OBJECTIVES The first objective of this study was to retrospectively evaluate zirconia-based restorations (ZBR). The second was to correlate failures with clinical parameters and to identify and to analyse chipping failures using fractographic analysis. METHODS 147 ZBR (tooth- and implant-supported crowns and fixed partial dentures (FPDs)) were evaluated after a mean observation period of 41.5 ± 31.8 months. Accessorily, zirconia implant abutments (n=46) were also observed. The technical (USPHS criteria) and the biological outcomes of the ZBR were evaluated. Occlusal risk factors were examined: occlusal relationships, parafunctional habits, and the presence of occlusal nightguard. SEM fractographic analysis was performed using the intra-oral replica technique. RESULTS The survival rate of crowns and FPDs was 93.2%, the success rate was 81.63% and the 9-year Kaplan-Meier estimated success rate was 52.66%. The chipping rate was 15% and the framework fracture rate was 2.7%. Most fractographic analyses revealed that veneer fractures originated from occlusal surface roughness. Several parameters were shown to significantly influence veneer fracture: the absence of occlusal nightguard (p=0.0048), the presence of a ceramic restoration as an antagonist (p=0.013), the presence of parafunctional activity (p=0.018), and the presence of implants as support (p=0.026). The implant abutments success rate was 100%. CONCLUSIONS The results of the present study confirm that chipping is the first cause of ZBR failure. They also underline the importance of clinical parameters in regards to the explanation of this complex problem. This issue should be considered in future prospective clinical studies. CLINICAL SIGNIFICANCE Practitioners can reduce chipping failures by taking into account several risk parameters, such as the presence of a ceramic restoration as an antagonist, the presence of parafunctional activity and the presence of implants as support. The use of an occlusal nightguard can also decrease failure rate.

Fit of single tooth zirconia copings: comparison between various manufacturing processes

STATEMENT OF PROBLEM Various CAD/CAM processes are commercially available to manufacture zirconia copings. Comparative data on their performance in terms of fit are needed. PURPOSE The purpose of this in vitro study was to compare the internal and marginal fit of single tooth zirconia copings manufactured with a CAD/CAM process (Procera; Nobel Biocare) and a mechanized manufacturing process (Ceramill; Amann Girrbach). MATERIAL AND METHODS Abutments (n=20) prepared in vivo for ceramic crowns served as a template for manufacturing both Procera and Ceramill zirconia copings. Copings were manufactured and cemented (Clearfil Esthetic Cement; Kuraray) on epoxy replicas of stone cast abutments. Specimens were sectioned. Nine measurements were performed for each coping. Over- and under-extended margins were evaluated. Comparisons between the 2 processes were performed with a generalized linear mixed model (α=.05). RESULTS Internal gap values between Procera and Ceramill groups were not significantly different (P=.13). The mean marginal gap (SD) for Procera copings (51(50) μm) was significantly smaller than for Ceramill (81(66) μm) (P<.005). The percentages of over- and under-extended margins were 43% and 57% for Procera respectively, and 71% and 29% for Ceramill. CONCLUSIONS Within the limitations of this in vitro study, the marginal fit of Procera copings was significantly better than that of Ceramill copings. Furthermore, Procera copings showed a smaller percentage of over-extended margins than did Ceramill copings.

Residual stress measurement in veneering ceramic by hole-drilling.

OBJECTIVES Mismatch in thermal expansion properties between veneering ceramic and metallic or high-strength ceramic cores can induce residual stresses and initiate cracks when combined with functional stresses. Knowledge of the stress distribution within the veneering ceramic is a key factor for understanding and predicting chipping failures, which are well-known problems with Yttria-tetragonal-zirconia-polycrystal based fixed partial dentures. The objectives of this study are to develop a method for measuring the stress profile in veneering ceramics and to compare ceramic-fused-to-metal compounds to veneered Yttria-tetragonal-zirconia-polycrystal ceramic. METHODS The hole-drilling method, often used for engineering measurements, was adapted for use with veneering ceramic. Because of the high sensitivity needed in comparison with industrial applications, a high sensitivity electrical measurement chain was developed. RESULTS All samples exhibited the same type of stress vs. depth profile, starting with compressive at the ceramic surface, decreasing with depth and becoming tensile at 0.5-1.0mm from the surface, and then becoming slightly compressive again. The zirconia samples exhibited a stress depth profile of larger magnitude. SIGNIFICANCE The hole drilling method was shown be a practical tool for measuring residual stresses in veneering ceramics.

Influence of cooling rate on residual stress profile in veneering ceramic: Measurement by hole-drilling

OBJECTIVES The manufacture of dental crowns and bridges generates residual stresses within the veneering ceramic and framework during the cooling process. Residual stress is an important factor that control the mechanical behavior of restorations. Knowing the stress distribution within the veneering ceramic as a function of depth can help the understanding of failures, particularly chipping, a well-known problem with Yttria-tetragonal-zirconia-polycrystal based fixed partial dentures. The objective of this study is to investigate the cooling rate dependence of the stress profile in veneering ceramic layered on metal and zirconia frameworks. METHODS The hole-drilling method, often used for engineering measurements, was adapted for use with veneering ceramic. The stress profile was measured in bilayered disc samples 20 mm in diameter, with a 0.7 mm thick metal or Yttria-tetragonal-zirconia-polycrystal framework and a 1.5mm thick veneering ceramic. Three different cooling procedures were investigated. RESULTS The magnitude of the stresses in the surface of the veneering ceramic was found to increase with cooling rate, while the interior stresses decreased. At the surface, compressive stresses were observed in all samples. In the interior, compressive stresses were observed in metal samples and tensile in zirconia samples. SIGNIFICANCE Cooling rate influences the magnitude of residual stresses. These can significantly influence the mechanical behavior of metal-and zirconia-based bilayered systems. The framework material influenced the nature of the interior stresses, with zirconia samples showing a less favorable stress profile than metal.

Influence of zirconia framework thickness on residual stress profile in veneering ceramic: Measurement by hole-drilling

OBJECTIVES Framework design is reported to influence chipping in zirconia-based restorations, which is an important cause of failure of such restorations. Residual stress profile in the veneering ceramic after the manufacturing process is an important predictive factor of the mechanical behavior of the material. The objective of this study is to investigate the influence of framework thickness on the stress profile measured in zirconia-based structures. METHODS The stress profile was measured with the hole-drilling method in bilayered disc samples of 20mm diameter with a 1.5 mm thick veneering ceramic layer. Six different framework thicknesses from 0.5 mm to 3 mm were studied. Two different cooling procedures were also investigated. RESULTS Compressive stresses were observed in the surface, and tensile stresses in the depth of most of the samples. The slow cooling procedure was found to promote the development of interior tensile stresses, except for the sample with a 3mm thick framework. With the tempering procedure, samples with a 1.5 mm thick framework exhibited the most favorable stress profile, while thicker and thinner frameworks exhibited respectively in surface or interior tensile stresses. SIGNIFICANCE The measurements performed highlight the importance of framework thickness, which determine the nature of stresses and can explain clinical failures encountered, especially with thin frameworks. The adequate ratio between veneering ceramic and zirconia is hard to define, restricting the range of indications of zirconia-based restorations until a better understanding of such a delicate veneering process is achieved.

Influence of veneer thickness on residual stress profile in veneering ceramic: Measurement by hole-drilling

OBJECTIVES The veneering process of frameworks induces residual stresses and can initiate cracks when combined with functional stresses. The stress distribution within the veneering ceramic as a function of depth is a key factor influencing failure by chipping. This is a well-known problem with Yttria-tetragonal-zirconia-polycrystal based fixed partial dentures. The objective of this study is to investigate the influence of veneer thickness on the stress profile in zirconia- and metal-based structures. METHODS The hole-drilling method, often used for engineering measurements, was adapted for use with veneering ceramic. The stress profile was measured in bilayered disc samples of 20 mm diameter, with a 1 mm thick zirconia or metal framework. Different veneering ceramic thicknesses were performed: 1 mm, 1.5 mm, 2 mm, 2.5 mm and 3 mm. RESULTS All samples exhibited the same type of stress vs. depth profile, starting with compressive at the ceramic surface, decreasing with depth up to 0.5-1.0 mm from the surface, and then becoming compressive again near the framework, except for the 1.5 mm-veneered zirconia samples which exhibited interior tensile stresses. Stresses in the surface of metal samples were not influenced by veneer thickness. Variation of interior stresses at 1.2 mm from the surface in function of veneer thickness was inverted for metal and zirconia samples. SIGNIFICANCE Veneer thickness influences in an opposite way the residual stress profile in metal- and in zirconia-based structures. A three-step approach and the hypothesis of the crystalline transformation are discussed to explain the less favorable residual stress development in zirconia samples.

No post-no core approach to restore severely damaged posterior teeth: An up to 10-year retrospective study of documented endocrown cases

OBJECTIVES The objectives of the present study were to (1) retrospectively evaluate documented cases of ceramic and composite endocrowns performed using immediate dentin sealing (IDS); (2) correlate failures with clinical parameters such as tooth preparation characteristics and occlusal parameters. METHODS 99 documented cases of endocrowns were evaluated after a mean observation period of 44.7±34.6months. A classification of restorations was established in function of the level of damage of residual tooth tissues after preparation, from 1 to 3. Evaluation was performed according to FDI criteria and endodontic outcomes were analyzed. Occlusal risk factors were examined and fractographic analysis was performed in case of fracture. RESULTS 48.4% of patients were shown to present occlusal risk factors. 75.8% of restorations were Class 3 endocrowns. 56.6% were performed on molars, 41.4% on premolars and 2.0% on canines. 84.8% were performed in lithium-disilicate glass-ceramic and 12.1% in Polymer-Infiltrated Ceramic Network (PICN) material. The survival and success rates of endocrowns were 99.0% and 89.9% respectively, while the 10-year Kaplan-Meier estimated survival and success rates were 98.8% and 54.9% respectively. Ten failures were detected: periodontal disease (n=3), endocrown debonding (n=2), minor chipping (n=2), caries recurrence (n=2) and major fractures (n=1). Due to the reduced amount of failures, no statistical correlation could be established with clinical parameters. CONCLUSIONS Endocrowns were shown to constitute a reliable approach to restore severely damaged molars and premolars, even in the presence of extensive coronal tissue loss or occlusal risk factors, such as bruxism or unfavorable occlusal relationships. CLINICAL SIGNIFICANCE Practitioners should consider the endocrown instead of the post and core approach to restore severely damaged non-vital posterior teeth. This minimally invasive solution reduces the risk of catastrophic failures and is easily performed. The use of IDS procedure and lithium-disilicate glass-ceramic as prosthesis material gave very good results.

Biocompatibility of polymer-infiltrated-ceramic-network (PICN) materials with Human Gingival Keratinocytes (HGKs)

OBJECTIVE Biocompatibility of polymer-infiltrated-ceramic-network (PICN) materials, a new class of CAD-CAM composites, is poorly explored in the literature, in particular, no data are available regarding Human Gingival Keratinocytes (HGK). The first objective of this study was to evaluate the in vitro biocompatibility of PICNs with HGKs in comparison with other materials typically used for implant prostheses. The second objective was to correlate results with PICN monomer release and indirect cytotoxicity. METHODS HGK attachment, proliferation and spreading on PICN, grade V titanium (Ti), yttrium zirconia (Zi), lithium disilicate glass-ceramic (eM) and polytetrafluoroethylene (negative control) discs were evaluated using a specific insert-based culture system. For PICN and eM samples, monomer release in the culture medium was quantified by high performance liquid chromatography and indirect cytotoxicity tests were performed. RESULTS Ti and Zi exhibited the best results regarding HGK viability, number and coverage. eM showed inferior results while PICN showed statistically similar results to eM but also to Ti regarding cell number and to Ti and Zi regarding cell viability. No monomer release from PICN discs was found, nor indirect cytotoxicity, as for eM. SIGNIFICANCE The results confirmed the excellent behavior of Ti and Zi with gingival cells. Even if polymer based, PICN materials exhibited intermediate results between Ti-Zi and eM. These promising results could notably be explained by PICN high temperature-high pressure (HT-HP) innovative polymerization mode, as confirmed by the absence of monomer release and indirect cytotoxicity.

Biocompatibility of polymer-infiltrated-ceramic-network (PICN) materials with Human Gingival Fibroblasts (HGFs).

OBJECTIVES Polymer-infiltrated-ceramic-network (PICN) materials constitute an innovative class of CAD-CAM materials offering promising perspectives in prosthodontics, but no data are available in the literature regarding their biological properties. The objective of the present study was to evaluate the in vitro biocompatibility of PICNs with human gingival fibroblasts (HGFs) in comparison with materials typically used for implant prostheses and abutments. METHODS HGF attachment, proliferation and spreading on discs made of PICN, grade V titanium (Ti), yttrium zirconia (Zi), lithium disilicate glass-ceramic (eM) and polytetrafluoroethylene (negative control), were evaluated using a specific insert-based culture system (IBS-R). Sample surface properties were characterized by XPS, contact angle measurement, profilometry and SEM. RESULTS Ti and Zi gave the best results regarding HGF viability, morphology, number and coverage increase with time in comparison with the negative control, while PICN and eM gave intermediate results, cell spreading being comparable for PICN, Ti, Zi and eM. Despite the presence of polymers and their related hydrophobicity, PICN exhibited comparable results to glass-ceramic materials, which could be explained by the mode of polymerization of the monomers. SIGNIFICANCE The results of the present study confirm that the currently employed materials, i.e. Ti and Zi, can be considered to be the gold standard of materials in terms of HGF behavior, while PICN gave intermediate results comparable to eM. The impact of the present in vitro results needs to be further investigated clinically, particularly in the view of the utilization of PICNs for prostheses on bone-level implants.

Aging of monolithic zirconia dental prostheses: Protocol for a 5-year prospective clinical study using ex vivo analyses

Background Recent introduction of computer-aided design/computer-aided manufacturing (CAD/CAM) monolithic zirconia dental prostheses raises the issue of material low thermal degradation (LTD), a well-known problem with zirconia hip prostheses. This phenomenon could be accentuated by masticatory mechanical stress. Until now zirconia LTD process has only been studied in vitro. This work introduces an original protocol to evaluate LTD process of monolithic zirconia prostheses in the oral environment and to study their general clinical behavior, notably in terms of wear. Methods/design 101 posterior monolithic zirconia tooth elements (molars and premolars) are included in a 5-year prospective clinical trial. On each element, several areas between 1 and 2 mm2 (6 on molars, 4 on premolars) are determined on restoration surface: areas submitted or non-submitted to mastication mechanical stress, glazed or non-glazed. Before prosthesis placement, ex vivo analyses regarding LTD and wear are performed using Raman spectroscopy, SEM imagery and 3D laser profilometry. After placement, restorations are clinically evaluated following criteria of the World Dental Federation (FDI), complemented by the analysis of fracture clinical risk factors. Two independent examiners perform the evaluations. Clinical evaluation and ex vivo analyses are carried out after 6 months and then each year for up to 5 years. Discussion For clinicians and patients, the results of this trial will justify the use of monolithic zirconia restorations in dental practice. For researchers, the originality of a clinical study including ex vivo analyses of material aging will provide important data regarding zirconia properties. Trial registration: ClinicalTrials.gov Identifier: NCT02150226.