Amélie Mainjot

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.

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.

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.

3D-Characterization of the veneer–zirconia interface using FIB nano-tomography

OBJECTIVES The phenomena occurring during zirconia frameworks veneering process are not yet fully understood. In particular the study of zirconia behavior at the interface with the veneer remains a challenge. However this interface has been reported to act on residual stress in the veneering ceramic, which plays a significant role in clinical failures such as chipping. The objective of this study was thus to investigate the veneer-zirconia interface using a recent 3D-analysis tool and to confront these observations to residual stress measurements in the veneering ceramic. METHODS Two cross-sectioned bilayered disc samples (veneer on zirconia), exhibiting different residual stress profiles in the veneering ceramic, were investigated using 2D and 3D imaging (respectively Scanning Electron Microscopy (SEM) and Focused Ion Beam nanotomography (FIB-nt), associated with chemical analysis by Energy Dispersive X-ray Spectroscopy (EDS). RESULTS The observations did not reveal any structural change in the bulk of zirconia layer of both samples. However the presence of structural alterations and sub-surface microcracks were highlighted in the first micrometer of zirconia surface, exclusively for the sample exhibiting interior tensile stress in the veneering ceramic. No interdiffusion phenomena were observed. SIGNIFICANCE FIB nanotomography was proven to be a powerful technique to study the veneer-zirconia interface. The determination of the origin and the nature of zirconia alterations need to be further studied. The results of the present study support the hypothesis that zirconia surface property changes could be involved in the development of tensile stress in the veneering ceramic, increasing the risk of chipping.

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.

Influence of thermal expansion mismatch on residual stress profile in veneering ceramic layered on zirconia: Measurement by hole-drilling.

OBJECTIVES Mismatch in thermal expansion coefficient between core and veneering ceramic (Δα=αcore-αveneer, ppm/°C) is reported as a crucial parameter influencing veneer fractures with Yttria-tetragonal-zirconia-polycrystal (Y-TZP) prostheses, which still constitutes a misunderstood problem. However, the common positive Δα concept remains empirical. The objective of this study is to investigate the Δα dependence of residual stress profiles in veneering ceramic layered on Y-TZP frameworks. METHODS The stress profile was measured with the hole-drilling method in bilayered disc samples of 20mm diameter with a 0.7mm thick Y-TZP framework and a 1.5mm thick veneer layer. 3 commercial and 4 experimental veneering ceramics (n=3 per group) were used to obtain different Δα varying from -1.3ppm/°C to +3.2ppm/°C, which were determined by dilatometric analyses. RESULTS Veneer fractures were observed in samples with Δα≥+2.3 or ≤-0.3ppm/°C. Residual stress profiles measured in other groups showed compressive stresses in the surface, these stresses decreasing with depth and then becoming more compressive again near the interface. Small Δα variations were shown to induce significant changes in residual stress profiles. Compressive stress near the framework was found to decrease inversely to Δα. SIGNIFICANCE Veneer CTE close to Y-TZP (+0.2ppm/°C Δα) gived the most favorable stress profile. Yet, near the framework, Δα-induced residual stress varied inversely to predictions. This could be explained by the hypothesis of structural changes occurrence within the Y-TZP surface. Consequently, the optimum Δα value cannot be determined before understanding Y-TZPs particular behavior when veneered.